Basic Information
Provider Information | |||||||||
NPI: | 1487008736 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NICHOLE MENTZER LCSW PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 419 W GRAY ST | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730697117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053297300 | ||||||||
FaxNumber: | 4053645379 | ||||||||
Practice Location | |||||||||
Address1: | 1745 NW 16TH ST | ||||||||
Address2: | STE A | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731062067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052010620 | ||||||||
FaxNumber: | 4053645379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2016 | ||||||||
LastUpdateDate: | 04/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MENTZER | ||||||||
AuthorizedOfficialFirstName: | NICHOLE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 4052010620 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5444 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.