Basic Information
| Provider Information | |||||||||
| NPI: | 1447520879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOBATO | ||||||||
| FirstName: | BRANDELINE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST # 274 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052719494 | ||||||||
| FaxNumber: | 4052713727 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 NE 10TH ST STE 3C | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715239 | ||||||||
| FaxNumber: | 4052713727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2012 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5750 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200548480A | 05 | OK | MEDICAID | 5750 | 01 | OK | LICENSED CLINICAL SOCIAL WORKER LICENSE | OTHER |