Provider Demographics
NPI:1336253467
Name:MABRAY, MYRA A
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:A
Last Name:MABRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 209
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:OK
Mailing Address - Zip Code:74570-9536
Mailing Address - Country:US
Mailing Address - Phone:918-424-1661
Mailing Address - Fax:918-420-5717
Practice Address - Street 1:400 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5464
Practice Address - Country:US
Practice Address - Phone:918-420-5238
Practice Address - Fax:918-420-5717
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK531101YA0400X
OK3348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health