Healthcare Provider Details

I. General information

NPI: 1407672371
Provider Name (Legal Business Name): KYLIE MICHELLE MOAK MASTERS STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 S WESTERN AVE
OKLAHOMA CITY OK
73139-1717
US

IV. Provider business mailing address

3841 NW 24TH ST
OKLAHOMA CITY OK
73107-1403
US

V. Phone/Fax

Practice location:
  • Phone: 405-939-5800
  • Fax:
Mailing address:
  • Phone: 720-756-5715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: