=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689032401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW START MHSA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2016
-----------------------------------------------------
Last Update Date | 02/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 E MAIN ST
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73030-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-514-6461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 E MAIN ST
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73030-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | AMANDA BREWER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-514-6461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------