Healthcare Provider Details

I. General information

NPI: 1316565617
Provider Name (Legal Business Name): BRIAN BARNES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E AVENUE C
HEAVENER OK
74937-2603
US

IV. Provider business mailing address

PO BOX 91
CAMERON OK
74932-0091
US

V. Phone/Fax

Practice location:
  • Phone: 918-658-4016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102790
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: