Healthcare Provider Details

I. General information

NPI: 1023979937
Provider Name (Legal Business Name): BRYAN R HOOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18483 HILLTOP CIR
TAHLEQUAH OK
74464-6129
US

IV. Provider business mailing address

18483 HILLTOP CIR
TAHLEQUAH OK
74464-6129
US

V. Phone/Fax

Practice location:
  • Phone: 572-247-8015
  • Fax:
Mailing address:
  • Phone: 572-247-8015
  • Fax: 572-247-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: