Provider Demographics
NPI:1679335558
Name:CARLTON, VIRGINIA GRACE
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:GRACE
Last Name:CARLTON
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 1:1053 RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2228
Mailing Address - Country:US
Mailing Address - Phone:918-352-1387
Mailing Address - Fax:
Practice Address - Street 1:11982 S MULBERRY CT
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2181
Practice Address - Country:US
Practice Address - Phone:918-201-1865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician