Healthcare Provider Details

I. General information

NPI: 1972829901
Provider Name (Legal Business Name): LISA DE AMBER KOMAHCHEET LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMBER KOMAHCHEET LADC

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 SW 104TH TER 2915 N CLASSEN BLVD. SUITE 325
OKLAHOMA CITY OK
73159-7800
US

IV. Provider business mailing address

3212 SW 104TH TER
OKLAHOMA CITY OK
73159-7800
US

V. Phone/Fax

Practice location:
  • Phone: 405-213-3700
  • Fax: 405-208-4574
Mailing address:
  • Phone: 405-213-3700
  • Fax: 405-208-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number#588
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: