MEDICARE: ODETE CARNEIRO PHARES MS/HR

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		OK

General Provider Information

NPI Number	:	1245504430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODETE CARNEIRO PHARES MS/HR

Provider Business Mailing Address
First Line	:	22183 COUNTY ROAD 3 DR
Second Line	:
City	:	STONEWALL
State	:	OK
Zip	:	74871-2021
Country	:	US
Telephone Number	:	580-265-4649
Fax Number	:

Provider Business Practice Location Address
First Line	:	22183 COUNTY ROAD 3 DR
Second Line	:
City	:	STONEWALL
State	:	OK
Zip	:	74871-2021
Country	:	US
Telephone Number	:	580-265-4649
Fax Number	:

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

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	03/06/2012

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