Healthcare Provider Details

I. General information

NPI: 1790105922
Provider Name (Legal Business Name): ANNA MARIE PERDUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910785 S GERDES DRIVE
WELLSTON OK
74881-8146
US

IV. Provider business mailing address

910785 S GERDES DRIVE
WELLSTON OK
74881-8146
US

V. Phone/Fax

Practice location:
  • Phone: 405-823-4415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5305
License Number StateOK

VIII. Authorized Official

Name: ANNA MARIE PERDUE
Title or Position: OWNER
Credential:
Phone: 405-823-4415