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General NPI Number Information
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NPI Number | 1225561053
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Entity Type | Individual
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Provider Name | MAE MOON BURKHALTER A.S.S
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Gender | Female
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Dates
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Enumeration Date | 04/08/2017
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Last Update Date | 04/08/2017
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Provider Practice Location Address
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Address Line | 409 NW 11TH ST APT 15
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City | OKLAHOMA CITY
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State | OK
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Zip | 73103-3915
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Country | US
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Telephone | 918-631-6380
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Fax |
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Provider Business Mailing Address
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Address Line | 409 NW 11TH ST APT 15
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City | OKLAHOMA CITY
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State | OK
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Zip | 73103-3915
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Country | US
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Telephone | 918-361-6380
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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