Healthcare Provider Details

I. General information

NPI: 1386996296
Provider Name (Legal Business Name): EARL WAYNE HARTFIELD JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N LEACH AVE
WATONGA OK
73772-3634
US

IV. Provider business mailing address

321 N LEACH AVE
WATONGA OK
73772-3634
US

V. Phone/Fax

Practice location:
  • Phone: 580-791-2948
  • Fax:
Mailing address:
  • Phone: 580-791-2948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: