=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861765059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE SHANTAI DURANT BS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2012
-----------------------------------------------------
Last Update Date | 02/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 NE 36TH ST STE G
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73111-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-270-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 NW 122ND ST APT 3406
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73120-8459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-622-6897
-----------------------------------------------------
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 | F083366435
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------