MEDICARE: KYLE L CUDJOE BA, MA

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

General Provider Information

NPI Number	:	1508119058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE L CUDJOE BA, MA

Provider Business Mailing Address
First Line	:	3301 NORCREST DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73121-1839
Country	:	US
Telephone Number	:	405-558-1758
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 NORCREST DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73121-1839
Country	:	US
Telephone Number	:	405-558-1758
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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