Healthcare Provider Details

I. General information

NPI: 1972838787
Provider Name (Legal Business Name): DAVY DILLARD/MADEWELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 N WASHINGTON ST
ARDMORE OK
73401-7013
US

IV. Provider business mailing address

32 N WASHINGTON ST
ARDMORE OK
73401-7013
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-5209
  • Fax: 580-371-3651
Mailing address:
  • Phone: 580-226-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: