=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679795124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID W PEACE BS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 W DELAWARE AVE
-----------------------------------------------------
City | VINITA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74301-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-323-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 W DELAWARE AVE
-----------------------------------------------------
City | VINITA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74301-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-323-0777
-----------------------------------------------------
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 |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4915
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------