Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1134351844 |
---|---|
Provider Name | Ellisworth Hardiman |
First Address | Chandler, OK 74834-4219 |
Second Address | Chandler, OK 74834-4219 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2009 |
Last Update Date | 13/08/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
081015740 | (05) | OK |