Healthcare Provider Details

I. General information

NPI: 1326179599
Provider Name (Legal Business Name): SANDE NICKEISHA SWABY LADC INTENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N OKLAHOMA AVE
OKLAHOMA CITY OK
73105-2724
US

IV. Provider business mailing address

229 CHALMETTE DR APT B
NORMAN OK
73071-2880
US

V. Phone/Fax

Practice location:
  • Phone: 405-552-8868
  • Fax: 405-528-8692
Mailing address:
  • Phone: 405-524-1076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: