=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770022519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL CORDELL WEST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4912 S WESTERN AVE STE A
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73109-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-819-6788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12101 N MACARTHUR BLVD #310
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73162-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-819-6788
-----------------------------------------------------
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 | C001419787
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------