Healthcare Provider Details

I. General information

NPI: 1265891246
Provider Name (Legal Business Name): ROBERT NATHANIEL WHEELER SR. LADC M/H
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S MUSKOGEE AVE
TAHLEQUAH OK
74464-4717
US

IV. Provider business mailing address

711 S MUSKOGEE AVE
TAHLEQUAH OK
74464-4717
US

V. Phone/Fax

Practice location:
  • Phone: 918-226-1219
  • Fax:
Mailing address:
  • Phone: 918-226-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1427
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier200556050A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: