Provider Demographics
NPI:1992130462
Name:NEALY, MARCUS
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:NEALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-3257
Mailing Address - Country:US
Mailing Address - Phone:405-209-5989
Mailing Address - Fax:866-422-5922
Practice Address - Street 1:7901 NE 10TH ST
Practice Address - Street 2:A209
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3600
Practice Address - Country:US
Practice Address - Phone:405-209-5989
Practice Address - Fax:866-422-5922
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200497040AMedicaid