Healthcare Provider Details

I. General information

NPI: 1316283245
Provider Name (Legal Business Name): JIM LEE TRAMMELL M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W. SHAWNEE ST
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

113 W SHAWNEE ST
TAHLEQUAH OK
74464-3623
US

V. Phone/Fax

Practice location:
  • Phone: 918-825-1405
  • Fax: 918-825-1406
Mailing address:
  • Phone: 918-825-1405
  • Fax: 918-825-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier200046400A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: