Healthcare Provider Details

I. General information

NPI: 1811415656
Provider Name (Legal Business Name): SAMANTHA RAE GARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E 6TH ST
PAWHUSKA OK
74056-4204
US

IV. Provider business mailing address

124 E 6TH ST
PAWHUSKA OK
74056-4204
US

V. Phone/Fax

Practice location:
  • Phone: 918-604-6054
  • Fax: 918-777-9018
Mailing address:
  • Phone: 918-604-6054
  • Fax: 918-777-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7131
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: