MEDICARE: MRS. CYNTHIA DERVAES L.P.C.

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	101YP2500X	Professional Counselor	5717	OK

General Provider Information

NPI Number	:	1699155572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CYNTHIA DERVAES L.P.C.

Provider Business Mailing Address
First Line	:	301 W WASHINGTON AVE
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-4448
Country	:	US
Telephone Number	:	719-440-8607
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 W WASHINGTON AVE
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-4448
Country	:	US
Telephone Number	:	719-440-8607
Fax Number	:

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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