Provider Demographics
NPI:1386961092
Name:CHARLSON, CICELY
Entity type:Individual
Prefix:MRS
First Name:CICELY
Middle Name:
Last Name:CHARLSON
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 1:1021 W 117TH ST S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5025
Mailing Address - Country:US
Mailing Address - Phone:918-360-9841
Mailing Address - Fax:
Practice Address - Street 1:1021 W 117TH ST S
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-5025
Practice Address - Country:US
Practice Address - Phone:918-360-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor