Healthcare Provider Details

I. General information

NPI: 1518458439
Provider Name (Legal Business Name): WALTER E COOPER RECOVERY TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 NW 25TH ST
OKLAHOMA CITY OK
73106-5629
US

IV. Provider business mailing address

3412 SPRINGLAKE DR. 26
OKLAHOMA CITY OK
73105
US

V. Phone/Fax

Practice location:
  • Phone: 405-525-2525
  • Fax:
Mailing address:
  • Phone: 405-905-8397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: