MEDICARE: INDIVIDUAL CONTRACTOR

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	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1689967531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIVIDUAL CONTRACTOR

Provider Business Mailing Address
First Line	:	4711 SE 77TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-4544
Country	:	US
Telephone Number	:	405-921-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	4711 SE 77TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-4544
Country	:	US
Telephone Number	:	405-921-3430
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIOR REHABILITATION SPECIALIST
Name	:	CRYSTAL L WALLS
Credential	:
Telephone Number	:	405-921-3430

Provider Enumeration Date	:	05/25/2011
Last Update Date	:	10/27/2011

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Directions to “INDIVIDUAL CONTRACTOR ” Practice Location

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