Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 2945 | OK |
NPI | 1003021106 |
---|---|
Provider Name | Ms. Suzie Deann Braddock |
First Address | Altus, OK 73521-1348 |
Second Address | Altus, OK 73521-1348 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2007 |
Last Update Date | 08/07/2007 |