Provider Demographics
NPI:1649495045
Name:SPRY, NICOLE L
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:SPRY
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 1:1028 NE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-5428
Mailing Address - Country:US
Mailing Address - Phone:580-468-2798
Mailing Address - Fax:
Practice Address - Street 1:1028 NE 4TH STREET
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-1739
Practice Address - Country:US
Practice Address - Phone:580-651-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)