Provider Demographics
NPI:1689967531
Name:INDIVIDUAL CONTRACTOR
Entity Type:Organization
Organization Name:INDIVIDUAL CONTRACTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR REHABILITATION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-921-3430
Mailing Address - Street 1:4711 SE 77TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-4544
Mailing Address - Country:US
Mailing Address - Phone:405-921-3430
Mailing Address - Fax:
Practice Address - Street 1:4711 SE 77TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-4544
Practice Address - Country:US
Practice Address - Phone:405-921-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health