Provider Demographics
NPI:1164039756
Name:SERGOTT, CASEY ELIZABETH
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ELIZABETH
Last Name:SERGOTT
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 1:7723 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1246
Mailing Address - Country:US
Mailing Address - Phone:618-610-6436
Mailing Address - Fax:
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4059
Practice Address - Country:US
Practice Address - Phone:405-564-3408
Practice Address - Fax:844-270-2039
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-20-134512103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst