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NPI Code Detail

MEDICARE: DORIE ELIZABETH WATTERS BSW

MEDICARE: DORIE ELIZABETH WATTERS BSW
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1578768909
Entity Type Code : Individual
Provider Name (Legal Business Name) : DORIE ELIZABETH WATTERS BSW
Provider Business Mailing Address
First Line : 711 S MUSKOGEE AVE
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-4717
Country : US
Telephone Number : 918-207-0078
Fax Number : 918-207-0558
Provider Business Practice Location Address
First Line : 711 S MUSKOGEE AVE
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-4717
Country : US
Telephone Number : 918-207-0078
Fax Number : 918-207-0558
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/16/2007
Last Update Date : 07/28/2014

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