Healthcare Provider Details

I. General information

NPI: 1407979958
Provider Name (Legal Business Name): JOHNNY MARK KIRK LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 N CINCINNATI
TULSA OK
74106-1536
US

IV. Provider business mailing address

650 S PEORIA
TULSA OK
74120-4429
US

V. Phone/Fax

Practice location:
  • Phone: 918-425-4200
  • Fax: 918-425-4202
Mailing address:
  • Phone: 918-587-9471
  • Fax: 918-560-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number582
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: