Healthcare Provider Details

I. General information

NPI: 1457179095
Provider Name (Legal Business Name): DIANA BASURTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MOUNTAIN LAUREL WAY
NOBLE OK
73068-8625
US

IV. Provider business mailing address

201 MOUNTAIN LAUREL WAY
NOBLE OK
73068-8625
US

V. Phone/Fax

Practice location:
  • Phone: 405-641-1848
  • Fax:
Mailing address:
  • Phone: 405-641-1848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCCANDIDATE13587
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: