Provider Demographics
NPI:1598092819
Name:DALLAS, VIOLA (LADC UNDER SUPERVISI)
Entity Type:Individual
Prefix:
First Name:VIOLA
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LADC UNDER SUPERVISI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 S BOULEVARD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4731
Mailing Address - Country:US
Mailing Address - Phone:405-406-4803
Mailing Address - Fax:
Practice Address - Street 1:920 S BOULEVARD
Practice Address - Street 2:SUITE #103
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4731
Practice Address - Country:US
Practice Address - Phone:405-406-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor