MEDICARE: MR. JOHN MICHAEL WALTZ MSW

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	1041C0700X	Clinical Social Worker	542	OK

General Provider Information

NPI Number	:	1699737197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MICHAEL WALTZ MSW

Provider Business Mailing Address
First Line	:	5700 ARNOLD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73145-8105
Country	:	US
Telephone Number	:	405-734-4393
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 ARNOLD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73145-8105
Country	:	US
Telephone Number	:	405-734-4393
Fax Number	:

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	08/20/2008

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