Provider Demographics
NPI:1144627233
Name:ENGRAM, DENISE EVYONNE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:EVYONNE
Last Name:ENGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DENIS
Other - Middle Name:EVYONNE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4723 S ASH DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3464
Mailing Address - Country:US
Mailing Address - Phone:918-313-9602
Mailing Address - Fax:
Practice Address - Street 1:4723 S ASH DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-3464
Practice Address - Country:US
Practice Address - Phone:918-313-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility