Healthcare Provider Details

I. General information

NPI: 1609385749
Provider Name (Legal Business Name): DUSTY BUMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E WILL ROGERS BLVD
CLAREMORE OK
74017-6352
US

IV. Provider business mailing address

1010 E WILL ROGERS BLVD
CLAREMORE OK
74017-6352
US

V. Phone/Fax

Practice location:
  • Phone: 918-342-3334
  • Fax: 918-342-3367
Mailing address:
  • Phone: 918-342-3334
  • Fax: 918-342-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: