Provider Demographics
NPI:1962784330
Name:STATEN, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:STATEN
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 1:8415 E 81ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-8030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7049 FRANKOMA RD
Practice Address - Street 2:#6, ADMIN BLDG
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74131-2018
Practice Address - Country:US
Practice Address - Phone:918-960-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst