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Behavioral Health & Social Service Providers Counselor Addiction (Substance Use Disorder)

Provider NPI: 1720307135

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
5326 NW ELM AVE  LAWTON, OK 73505-4622 US
Tel: 580-574-0580  Fax: --

Business Mailing Address:
5326 NW ELM AVE  LAWTON, OK 73505-4622 US
Tel: 580-574-0580  Fax: --

NPI Information:
NPI: 1720307135
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y101YA0400XBehavioral Health & Social Service Providers
Addiction (Substance Use Disorder)

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 101YA0400X





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