=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457080962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. YUNJIANG HUANG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2022
-----------------------------------------------------
Last Update Date | 06/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 S COUNTY CLUB RD
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-718-4421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1145 N CEDAR AVE APT 52
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-7141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-718-4421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | CF455
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------