Healthcare Provider Details

I. General information

NPI: 1982112900
Provider Name (Legal Business Name): MICAH OWENS BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/11/2018
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

12264 SW 11TH ST
YUKON OK
73099-7024
US

V. Phone/Fax

Practice location:
  • Phone: 580-225-5136
  • Fax:
Mailing address:
  • Phone: 405-219-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: