Healthcare Provider Details

I. General information

NPI: 1700081130
Provider Name (Legal Business Name): SUSAN YEUTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HENSLEY DR
TAHLEQUAH OK
74464-5221
US

IV. Provider business mailing address

PO BOX 558
TAHLEQUAH OK
74465-0558
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-3028
  • Fax: 918-207-3064
Mailing address:
  • Phone: 918-207-3028
  • Fax: 918-207-3064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2636
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: