=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588868855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS SUSANNA L HALCOMB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7-1- S. YALE AVE, STE 215
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-492-2554
-----------------------------------------------------
Fax | 918-494-9870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4308 E 21ST PL
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74114-2114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-808-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------