Provider Demographics
NPI:1497009450
Name:EDWARDS, DEKOVEN M JR
Entity Type:Individual
Prefix:
First Name:DEKOVEN
Middle Name:M
Last Name:EDWARDS
Suffix:JR
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 1:10704 GREYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3216
Mailing Address - Country:US
Mailing Address - Phone:405-201-2171
Mailing Address - Fax:
Practice Address - Street 1:10704 GREYSTONE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-3216
Practice Address - Country:US
Practice Address - Phone:405-201-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid