MEDICARE: WALVET WILLIAMS

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	101YP2500X	Professional Counselor	200330980	OK

General Provider Information

NPI Number	:	1336492842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALVET WILLIAMS

Provider Business Mailing Address
First Line	:	236 NW 90TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-3611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	236 NW 90TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-3611
Country	:	US
Telephone Number	:	405-463-6804
Fax Number	:

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

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	10/22/2012

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