Healthcare Provider Details

I. General information

NPI: 1801121371
Provider Name (Legal Business Name): PAGE PELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 AKRON ST
ARDMORE OK
73401-1622
US

IV. Provider business mailing address

911 AKRON ST
ARDMORE OK
73401-1622
US

V. Phone/Fax

Practice location:
  • Phone: 589-037-1367
  • Fax: 580-371-3651
Mailing address:
  • Phone: 589-037-1367
  • Fax: 580-371-3651

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: