Provider Demographics
NPI:1447672332
Name:ROBINSON, CARNELL
Entity type:Individual
Prefix:
First Name:CARNELL
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7438
Mailing Address - Country:US
Mailing Address - Phone:405-648-7399
Mailing Address - Fax:
Practice Address - Street 1:2128 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73170-7438
Practice Address - Country:US
Practice Address - Phone:405-642-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKMC-2010101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0000000Medicaid