Provider Demographics
NPI:1558664094
Name:HART, ELIZABETH MICHELLE
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:HART
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:PO BOX 794
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0794
Mailing Address - Country:US
Mailing Address - Phone:580-371-6234
Mailing Address - Fax:
Practice Address - Street 1:2511 W MORROW RD
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-0794
Practice Address - Country:US
Practice Address - Phone:580-371-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation