Basic Information
Provider Information | |||||||||
NPI: | 1407180219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDRICKS | ||||||||
FirstName: | MARIANNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5525 E 51ST ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741357461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183886457 | ||||||||
FaxNumber: | 9183886456 | ||||||||
Practice Location | |||||||||
Address1: | 5525 E 51ST ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741357461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183886457 | ||||||||
FaxNumber: | 9183886456 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2009 | ||||||||
LastUpdateDate: | 09/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 100746170G | 05 | OK |   | MEDICAID |