Provider Demographics
NPI:1720527419
Name:ELDER, MARCY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARCY
Middle Name:
Last Name:ELDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2414 E SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1530
Mailing Address - Country:US
Mailing Address - Phone:918-577-3476
Mailing Address - Fax:918-682-1138
Practice Address - Street 1:2414 E SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1530
Practice Address - Country:US
Practice Address - Phone:918-577-3476
Practice Address - Fax:918-682-1138
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP2496103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist