Healthcare Provider Details

I. General information

NPI: 1134351844
Provider Name (Legal Business Name): ELLISWORTH HARDIMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 STEELE AVE
CHANDLER OK
74834-4219
US

IV. Provider business mailing address

1411 STEELE AVE
CHANDLER OK
74834-4219
US

V. Phone/Fax

Practice location:
  • Phone: 405-258-9193
  • Fax:
Mailing address:
  • Phone: 405-258-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: