Provider Demographics
NPI:1932092616
Name:LICASTRO, BROOKLYNN S
Entity type:Individual
Prefix:
First Name:BROOKLYNN
Middle Name:S
Last Name:LICASTRO
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 1:23597 192ND NW
Mailing Address - Street 2:
Mailing Address - City:GEARY
Mailing Address - State:OK
Mailing Address - Zip Code:73040-4306
Mailing Address - Country:US
Mailing Address - Phone:405-697-6706
Mailing Address - Fax:
Practice Address - Street 1:116 N BROAD ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-3367
Practice Address - Country:US
Practice Address - Phone:405-858-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist