MEDICARE: PAGNOLIA, 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
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1457984544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAGNOLIA, LLC

Provider Business Mailing Address
First Line	:	8800 S PENNSYLVANIA AVE STE 100
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5211
Country	:	US
Telephone Number	:	405-633-0316
Fax Number	:	405-839-8050

Provider Business Practice Location Address
First Line	:	8800 S PENNSYLVANIA AVE STE 100
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5211
Country	:	US
Telephone Number	:	405-633-0316
Fax Number	:	405-839-8050

Authorized Official
Title or Position	:	THERAPIST
Name	:	WES WARNER
Credential	:	LPC
Telephone Number	:	405-633-0316

Provider Enumeration Date	:	02/17/2020
Last Update Date	:	04/28/2022

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