MEDICARE: MR. BENNIE LEE BOYKIN M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1033321435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENNIE LEE BOYKIN M.ED.

Provider Business Mailing Address
First Line	:	1501 NE 11TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-2605
Country	:	US
Telephone Number	:	405-424-4347
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 NE 11TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-2605
Country	:	US
Telephone Number	:	405-424-4347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2007
Last Update Date	:	07/08/2007

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