MEDICARE: KRISTA M DOLL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6192	OK
2	101YP2500X	Professional Counselor	6192	OK
3	101Y00000X	Counselor	6192	OK

General Provider Information

NPI Number	:	1053851543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTA M DOLL LLC

Provider Business Mailing Address
First Line	:	4816 SW 129TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73173-8917
Country	:	US
Telephone Number	:	405-641-1084
Fax Number	:

Provider Business Practice Location Address
First Line	:	4816 SW 129TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73173-8917
Country	:	US
Telephone Number	:	405-641-1084
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA DOLL
Credential	:	M.ED., LPC
Telephone Number	:	405-641-1084

Provider Enumeration Date	:	03/02/2017
Last Update Date	:	03/02/2017

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