MEDICARE: TONYA LYNN GOLDNER PSRS

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1578894234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONYA LYNN GOLDNER PSRS

Provider Business Mailing Address
First Line	:	PO BOX 452014
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74345-2014
Country	:	US
Telephone Number	:	918-787-8904
Fax Number	:

Provider Business Practice Location Address
First Line	:	1629 S MAIN ST
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74344-5368
Country	:	US
Telephone Number	:	918-791-9700
Fax Number	:

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

Provider Enumeration Date	:	01/20/2010
Last Update Date	:	01/20/2010

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