MEDICARE: MRS. TRACIE R GARRETT M.S., LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	0966450804	OK
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	691	OK

General Provider Information

NPI Number	:	1487770061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACIE R GARRETT M.S., LADC

Provider Business Mailing Address
First Line	:	4911 N PORTLAND AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6171
Country	:	US
Telephone Number	:	405-751-0800
Fax Number	:	405-751-6488

Provider Business Practice Location Address
First Line	:	4911 N PORTLAND AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6171
Country	:	US
Telephone Number	:	405-751-0800
Fax Number	:	405-751-6488

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	09/22/2020

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