Provider Demographics
NPI:1679795124
Name:PEACE, DAVID W (BS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:PEACE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-3922
Mailing Address - Country:US
Mailing Address - Phone:918-323-0777
Mailing Address - Fax:
Practice Address - Street 1:1104 W DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-3922
Practice Address - Country:US
Practice Address - Phone:918-323-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK4915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health