MEDICARE: MRS. LATASHA MARIE CRUIKSHANK

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1407107758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATASHA MARIE CRUIKSHANK

Provider Business Mailing Address
First Line	:	PO BOX 60933
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73146-0933
Country	:	US
Telephone Number	:	405-637-8996
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 GARLAND AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-4710
Country	:	US
Telephone Number	:	405-637-8996
Fax Number	:

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

Provider Enumeration Date	:	09/26/2012
Last Update Date	:	09/26/2012

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