Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003246505 |
---|---|
Provider Name | Natasha Tom |
First Address | Mead, OK 73449-0048 |
Second Address | Durant, OK 74701-4700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/11/2013 |
Last Update Date | 19/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100708380 | (05) | OK |
200049040 | (05) | OK |