Provider Demographics
NPI:1043778061
Name:SCROGGINS, KAMILAH
Entity Type:Individual
Prefix:
First Name:KAMILAH
Middle Name:
Last Name:SCROGGINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68512 S 310 RD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-6276
Mailing Address - Country:US
Mailing Address - Phone:661-972-8815
Mailing Address - Fax:
Practice Address - Street 1:68512 S 310 RD
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-6276
Practice Address - Country:US
Practice Address - Phone:661-972-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKKF14188815Medicaid