Healthcare Provider Details

I. General information

NPI: 1285546499
Provider Name (Legal Business Name): DANIELLE C BOLIVAR
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S HARRILL AVE
WAGONER OK
74467-5317
US

IV. Provider business mailing address

109 S HARRILL AVE
WAGONER OK
74467-5317
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-0242
  • Fax: 918-485-0204
Mailing address:
  • Phone: 918-485-0242
  • Fax: 918-485-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: