=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184445173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANCH WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 LEXINGTON AVE
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73601-5320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-401-4693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 132
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73601-0132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-401-4693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | HALEY JORDAN NUNN
-----------------------------------------------------
Credential | MS. LPC
-----------------------------------------------------
Telephone | 405-401-4693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------