Provider Demographics
NPI:1336529254
Name:MABRY, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MABRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4415
Mailing Address - Country:US
Mailing Address - Phone:918-448-8154
Mailing Address - Fax:918-465-0301
Practice Address - Street 1:301 E MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4415
Practice Address - Country:US
Practice Address - Phone:918-448-8154
Practice Address - Fax:918-465-0301
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator