Provider Demographics
NPI:1083984678
Name:BREWER, NATHANIEL DALE
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:DALE
Last Name:BREWER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 SW 116TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-4461
Mailing Address - Country:US
Mailing Address - Phone:405-314-7933
Mailing Address - Fax:
Practice Address - Street 1:2324 N INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2942
Practice Address - Country:US
Practice Address - Phone:405-361-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor