=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649975905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER NEBHUT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2023
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S MONROE ST STE 6
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-5761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-374-3976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 806 N WASHINGTON AVE
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------