Provider Demographics
NPI:1245528504
Name:VALGREN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VALGREN
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:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:CADDO
Mailing Address - State:OK
Mailing Address - Zip Code:74729
Mailing Address - Country:US
Mailing Address - Phone:580-367-9901
Mailing Address - Fax:
Practice Address - Street 1:715 NTH 1ST ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701
Practice Address - Country:US
Practice Address - Phone:580-931-3008
Practice Address - Fax:580-931-8022
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid