MEDICARE: DENA MUSGRAVES

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1306121785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENA MUSGRAVES

Provider Business Mailing Address
First Line	:	19850 CR 1680
Second Line	:
City	:	STONEWALL
State	:	OK
Zip	:	74871
Country	:	US
Telephone Number	:	817-229-4757
Fax Number	:

Provider Business Practice Location Address
First Line	:	19850 CR 1680
Second Line	:
City	:	STONEWALL
State	:	OK
Zip	:	74871
Country	:	US
Telephone Number	:	817-229-4757
Fax Number	:

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

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	10/17/2011

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