Healthcare Provider Details

I. General information

NPI: 1487983359
Provider Name (Legal Business Name): MISS MARY ETTA BILLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 E 12TH ST
TULSA OK
74120-5407
US

IV. Provider business mailing address

1620 E 12TH ST
TULSA OK
74120-5407
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-2131
  • Fax: 918-588-8822
Mailing address:
  • Phone: 918-582-2131
  • Fax: 918-588-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number355
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: