=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548859838
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ANN BOYLES MSW; LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 07/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E MEMORIAL RD STE 500
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73114-2287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-531-0726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 W COVELL RD UNIT 30903
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-2242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-531-0726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 8624
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------