=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972244473
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. SUSAN ASHLEY EAST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2022
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25604 MURPHY CT
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74019-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-557-2532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25604 MURPHY CT
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74019-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-557-2532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 416070
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------