Basic Information
| Provider Information | |||||||||
| NPI: | 1265884340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMARAIS | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3251 S 137TH EAST AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741344205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185302474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1334 N LANSING AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872171 | ||||||||
| FaxNumber: | 9185874534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 6922 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.