Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1366793879 |
---|---|
Provider Name | Mr. Reuben Julius Ingram |
First Address | Oklahoma City, OK 73112-2046 |
Second Address | Oklahoma City, OK 73112-5900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2012 |
Last Update Date | 24/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2009 | PASTOR/COUNSELOR (01) | OK |