MEDICARE: NATHANIEL DASH CADC

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	145	OK

General Provider Information

NPI Number	:	1619094851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANIEL DASH CADC

Provider Business Mailing Address
First Line	:	710 E SUTHERLAND ST
Second Line	:
City	:	ALTUS
State	:	OK
Zip	:	73521-4041
Country	:	US
Telephone Number	:	580-477-2871
Fax Number	:	580-477-4870

Provider Business Practice Location Address
First Line	:	2 WICKERSHAM ST
Second Line	:
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3337
Fax Number	:	580-782-3338

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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