=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396055182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WILLIAM HITCHCOCK PHD, LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2010
-----------------------------------------------------
Last Update Date | 11/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 YALE AVE
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74604-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-761-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 YALE AVE
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74604-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-761-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 686
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------