Provider Demographics
NPI:1972897106
Name:COUNTZ, KRYSTLE ELAINE (BA, CM II)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:ELAINE
Last Name:COUNTZ
Suffix:
Gender:F
Credentials:BA, CM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 W HALL RD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:OK
Mailing Address - Zip Code:74570-5192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5300
Practice Address - Country:US
Practice Address - Phone:918-421-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK310780171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator