=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528390846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISTI A. CENTER, LPC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2010
-----------------------------------------------------
Last Update Date | 02/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2504 E 21ST ST STE B
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74114-1759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-277-3746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2504 E 21ST ST STE B
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74114-1759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-277-3746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | MRS. MISTI A CENTER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 918-277-3746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3673
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------