MEDICARE: MS. STACY CAROL PREWITT B.A.

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	101Y00000X	Counselor		OK

General Provider Information

NPI Number	:	1518372929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY CAROL PREWITT B.A.

Provider Business Mailing Address
First Line	:	1300 HOPPE BLVD STE 6
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2319
Country	:	US
Telephone Number	:	580-436-1222
Fax Number	:	580-436-1333

Provider Business Practice Location Address
First Line	:	1300 HOPPE BLVD STE 6
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2319
Country	:	US
Telephone Number	:	580-436-1222
Fax Number	:	580-436-1333

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

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	06/24/2014

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