MEDICARE: RAVONDA LATRICE EDWARDS

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	UNDERSUPERVISION	OK

General Provider Information

NPI Number	:	1518297332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVONDA LATRICE EDWARDS

Provider Business Mailing Address
First Line	:	500 NW 171ST ST
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73012-6753
Country	:	US
Telephone Number	:	405-863-0851
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 N CLASSEN BLVD
Second Line	:	SUITE E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5809
Country	:	US
Telephone Number	:	405-528-0087
Fax Number	:

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

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	12/29/2009

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