MEDICARE: ELODIE BIRDWELL MSW

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	104100000X	Social Worker	5185-P	OK

General Provider Information

NPI Number	:	1437535002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELODIE BIRDWELL MSW

Provider Business Mailing Address
First Line	:	2804 E KNOXVILLE ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-2813
Country	:	US
Telephone Number	:	918-519-8735
Fax Number	:

Provider Business Practice Location Address
First Line	:	2804 E KNOXVILLE ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-2813
Country	:	US
Telephone Number	:	918-519-8735
Fax Number	:

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

Provider Enumeration Date	:	08/06/2015
Last Update Date	:	08/06/2015

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