Provider Demographics
NPI:1558887356
Name:KEMUNTO MAGATI, IDA S
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:S
Last Name:KEMUNTO MAGATI
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 1:2424 ASHEBURY WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5855
Mailing Address - Country:US
Mailing Address - Phone:405-588-7149
Mailing Address - Fax:
Practice Address - Street 1:626 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4814
Practice Address - Country:US
Practice Address - Phone:405-588-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)