=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063789709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIJA SELF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2011
-----------------------------------------------------
Last Update Date | 08/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 N WILLOW
-----------------------------------------------------
City | LEHIGH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-378-2920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 253
-----------------------------------------------------
City | LEHIGH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74556-0253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-298-2830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 7171
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------