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General NPI Number Information
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NPI Number | 1366795015
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Entity Type | Organization
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Legal Business Name | JP SPAVINAW CREEK LLC
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Dates
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Enumeration Date | 10/18/2012
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Last Update Date | 10/18/2012
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Provider Practice Location Address
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Address Line | 401 CENTER AVE
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City | SPAVINAW
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State | OK
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Zip | 74366-0353
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Country | US
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Telephone | 918-589-2160
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 353 401 CENTER AVENUE
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City | SPAVINAW
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State | OK
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Zip | 74366-0353
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Country | US
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Telephone | 918-589-2160
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Fax |
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Authorized Official
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Title or Position | MEMBER/PARTNER
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Name | MS. MARGARET AILEEN PLUMMER
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Credential | LCSW
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Telephone | 918-589-2160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0053
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2502
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License Number State | OK
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