Healthcare Provider Details

I. General information

NPI: 1184910952
Provider Name (Legal Business Name): CHERYL ANN BROOME MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 09/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 E ALMAR DR
CHICKASHA OK
73018-7327
US

IV. Provider business mailing address

816 SOUTH 20TH STREET
CHICKASHA OK
73018
US

V. Phone/Fax

Practice location:
  • Phone: 405-222-5437
  • Fax:
Mailing address:
  • Phone: 405-320-5584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: