Healthcare Provider Details

I. General information

NPI: 1275950941
Provider Name (Legal Business Name): MR. CHRISTOPHER ANDRAE TRAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40119 STATE HIGHWAY 59
BYARS OK
74831-7931
US

IV. Provider business mailing address

40119 STATE HIGHWAY 59
BYARS OK
74831-7931
US

V. Phone/Fax

Practice location:
  • Phone: 405-361-5055
  • Fax:
Mailing address:
  • Phone: 405-361-5055
  • 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: