Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | UNDER SUPERVISION |
NPI | 1285849497 |
---|---|
Provider Name | Julie Davis |
First Address | Ardmore, OK 73401-2529 |
Second Address | Ardmore, OK 73401-2503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2007 |
Last Update Date | 10/08/2007 |