Healthcare Provider Details

I. General information

NPI: 1740678614
Provider Name (Legal Business Name): MISTY LORRAINE MUSICK MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 W 3RD ST
ELK CITY OK
73644-4323
US

IV. Provider business mailing address

3080 W 3RD ST
ELK CITY OK
73644-4323
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-6021
  • Fax: 580-323-0828
Mailing address:
  • Phone: 580-323-6021
  • Fax: 580-323-0828

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: