Healthcare Provider Details

I. General information

NPI: 1619094851
Provider Name (Legal Business Name): NATHANIEL DASH CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WICKERSHAM ST
MANGUM OK
73554-9117
US

IV. Provider business mailing address

710 E SUTHERLAND ST
ALTUS OK
73521-4041
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-3337
  • Fax: 580-782-3338
Mailing address:
  • Phone: 580-477-2871
  • Fax: 580-477-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number145
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: