MEDICARE: EMMA GREENBACK

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		OK

General Provider Information

NPI Number	:	1881168045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA GREENBACK

Provider Business Mailing Address
First Line	:	PO BOX 957
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-0957
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8516 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5226
Country	:	US
Telephone Number	:	405-229-7972
Fax Number	:

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

Provider Enumeration Date	:	01/21/2019
Last Update Date	:	01/21/2019

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Directions to “ EMMA GREENBACK ” Practice Location

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