Provider Demographics
NPI:1699054841
Name:MCDONALD, LUCRETIA FAY
Entity type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:FAY
Last Name:MCDONALD
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 2 BOX 229-1
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-9427
Mailing Address - Country:US
Mailing Address - Phone:580-212-7610
Mailing Address - Fax:580-286-6385
Practice Address - Street 1:104 NE AVE A
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3813
Practice Address - Country:US
Practice Address - Phone:580-286-3301
Practice Address - Fax:580-286-6385
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)