Provider Demographics
NPI:1447875208
Name:CANTWELL, CATRINA BLAISE
Entity type:Individual
Prefix:MRS
First Name:CATRINA
Middle Name:BLAISE
Last Name:CANTWELL
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 1:620 NW 5TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3947
Mailing Address - Country:US
Mailing Address - Phone:405-208-4469
Mailing Address - Fax:405-208-4472
Practice Address - Street 1:620 NW 5TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3947
Practice Address - Country:US
Practice Address - Phone:405-208-4469
Practice Address - Fax:405-208-4472
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11302101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201133840AMedicaid