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General NPI Number Information
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NPI Number | 1013553163
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Entity Type | Individual
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Provider Name | MIRISSA JOY BEAVERS
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Gender | Female
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Dates
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Enumeration Date | 11/25/2019
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 4400 N LINCOLN BLVD
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City | OKLAHOMA CITY
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State | OK
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Zip | 73105-5104
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Country | US
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Telephone | 405-638-0961
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Fax |
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Provider Business Mailing Address
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Address Line | 3457 ROBIN DR
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City | WOODWARD
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State | OK
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Zip | 73801-3941
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Country | US
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Telephone | 580-216-4170
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8848
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License Number State | OK
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