Healthcare Provider Details

I. General information

NPI: 1912282567
Provider Name (Legal Business Name): BERTHEOPHILUS MAURICE BAILEY SR. MHR, BHRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 S 148TH EAST PL
TULSA OK
74134-4806
US

IV. Provider business mailing address

3426 S 148TH EAST PL
TULSA OK
74134-4806
US

V. Phone/Fax

Practice location:
  • Phone: 918-282-9385
  • Fax:
Mailing address:
  • Phone: 918-282-9385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: