MEDICARE: MICQUEAL L WARE

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	103K00000X	Behavior Analyst
2	101YP2500X	Professional Counselor	5999	OK

General Provider Information

NPI Number	:	1154614139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICQUEAL L WARE

Provider Business Mailing Address
First Line	:	4400 COLTRANE PL
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73121-6606
Country	:	US
Telephone Number	:	405-609-6169
Fax Number	:	405-609-6169

Provider Business Practice Location Address
First Line	:	11032 QUAIL CREEK RD STE 212
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6220
Country	:	US
Telephone Number	:	405-905-2074
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2011
Last Update Date	:	05/13/2020

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Directions to “ MICQUEAL L WARE ” Practice Location

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