Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1114339348 |
---|---|
Provider Name | John Walls |
First Address | Oklahoma City, OK 73107 |
Second Address | Oklahoma City, OK 73107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2014 |
Last Update Date | 22/05/2014 |