Healthcare Provider Details

I. General information

NPI: 1770531006
Provider Name (Legal Business Name): KRIS ICE MAT, LPC, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E TONHAWA ST
NORMAN OK
73069-7209
US

IV. Provider business mailing address

123 E TONHAWA ST
NORMAN OK
73069-7255
US

V. Phone/Fax

Practice location:
  • Phone: 405-364-2008
  • Fax: 405-364-4496
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2282
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: