=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134857147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREAD NOT MAMMOTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2022
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 CROSSROADS BLVD STE 106
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73072-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-765-3687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 757 SW 13TH ST
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-2685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-248-0185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | NICOLE BROWN
-----------------------------------------------------
Credential | LPC, LADC
-----------------------------------------------------
Telephone | 940-765-3687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------