Provider Demographics
NPI:1902039480
Name:WOOLLY, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:WOOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 N BROADWAY ST
Mailing Address - Street 2:BLD B
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2000
Mailing Address - Country:US
Mailing Address - Phone:918-649-0300
Mailing Address - Fax:918-649-0094
Practice Address - Street 1:2210 N BROADWAY ST
Practice Address - Street 2:BLDG B
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2000
Practice Address - Country:US
Practice Address - Phone:918-649-0300
Practice Address - Fax:918-649-0094
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor