Basic Information
Provider Information
NPI: 1003293994
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RUE
FirstName: MICHELLE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: B.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 34668 E COUNTY ROAD 1650
Address2:  
City: WYNNEWOOD
State: OK
PostalCode: 730989173
CountryCode: US
TelephoneNumber: 4056654385
FaxNumber: 4056656396
Practice Location
Address1: 202 S WASHITA AVE
Address2:  
City: WYNNEWOOD
State: OK
PostalCode: 730987820
CountryCode: US
TelephoneNumber: 4056654385
FaxNumber: 4056656396
Other Information
ProviderEnumerationDate: 04/30/2015
LastUpdateDate: 04/30/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103K00000X  Y Behavioral Health & Social Service ProvidersBehavioral Analyst 

No ID Information.


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