Provider Demographics
NPI:1013543719
Name:PROPHET, ADRIAN LAMAR (LMT)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:LAMAR
Last Name:PROPHET
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 MADISON CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W 15TH ST STE B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3642
Practice Address - Country:US
Practice Address - Phone:405-535-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK182962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK182962OtherMASSAGE THERAPIST