=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558568022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC L ROLEN B.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 S SHERIDAN RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74112-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-832-7764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15720 N 280 RD
-----------------------------------------------------
City | OKMULGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74447-8579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-832-7764
-----------------------------------------------------
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 |
-----------------------------------------------------