Healthcare Provider Details

I. General information

NPI: 1922669639
Provider Name (Legal Business Name): FLAVIO DE ANDRADE VITAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FLAVIO VITAL

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E I 35 FRONTAGE RD
EDMOND OK
73034-7327
US

IV. Provider business mailing address

325 WISDOM WAY
EDMOND OK
73003-3089
US

V. Phone/Fax

Practice location:
  • Phone: 405-340-7400
  • Fax:
Mailing address:
  • Phone: 405-856-3633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: