Provider Demographics
NPI:1669820049
Name:PRESCOTT, WINSTON SILVESTER JOHNSON
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:SILVESTER JOHNSON
Last Name:PRESCOTT
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 1:3412 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1742
Mailing Address - Country:US
Mailing Address - Phone:229-292-3932
Mailing Address - Fax:
Practice Address - Street 1:3412 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-1742
Practice Address - Country:US
Practice Address - Phone:229-292-3932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1669820049Medicaid