Provider Demographics
NPI:1902235641
Name:CAROLINA, TRESA
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:
Last Name:CAROLINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NW 39TH
Mailing Address - Street 2:STE 103
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-220-7158
Mailing Address - Fax:405-606-7893
Practice Address - Street 1:2401 NW 39TH
Practice Address - Street 2:STE 103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-220-7158
Practice Address - Fax:405-606-7893
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK302004171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200524840AMedicaid