Healthcare Provider Details

I. General information

NPI: 1487199527
Provider Name (Legal Business Name): SAMANTHA EZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BROADWAY ST 401
ARDMORE OK
73401-6205
US

IV. Provider business mailing address

PO BOX 1710
KINGSTON OK
73439-1710
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-5209
  • Fax: 580-226-5219
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: