=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396947305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTA SUE HEUSTIS LADC, (US)
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 E ADMIRAL PL
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74110-5436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-835-3017
-----------------------------------------------------
Fax | 918-836-0358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18921 W WEKIWA RD LOT 31
-----------------------------------------------------
City | SAND SPRINGS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74063-5970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-981-0833
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------