Healthcare Provider Details

I. General information

NPI: 1891990214
Provider Name (Legal Business Name): MARSHA COBELL-MOORE MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARSHA MOORE MSW LCSW

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HERITAGE CIR
PAWNEE OK
74058-3744
US

IV. Provider business mailing address

1201 HERITAGE CIR
PAWNEE OK
74058-3744
US

V. Phone/Fax

Practice location:
  • Phone: 918-762-2517
  • Fax: 918-762-6646
Mailing address:
  • Phone: 918-762-2517
  • Fax: 918-762-6646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5355
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: