=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801541636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA KAY PRIESTLY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2022
-----------------------------------------------------
Last Update Date | 02/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104544 S 4140 RD
-----------------------------------------------------
City | COUNCIL HILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74428-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-569-9058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104544 S 4140 RD
-----------------------------------------------------
City | COUNCIL HILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74428-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-569-9058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------