Healthcare Provider Details

I. General information

NPI: 1750167052
Provider Name (Legal Business Name): E-SCHOOL VIRTUAL CHARTER ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 S DIVISION ST STE B
GUTHRIE OK
73044-6031
US

IV. Provider business mailing address

2403 S DIVISION ST STE B
GUTHRIE OK
73044-6031
US

V. Phone/Fax

Practice location:
  • Phone: 833-203-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMMY SHEPARD
Title or Position: DIRECTOR OF FEDERAL PROGRAMS
Credential:
Phone: 833-203-4300