MEDICARE: ALBUS DIMABO EVANS-WILCOX MFT

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1922387653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALBUS DIMABO EVANS-WILCOX MFT

Provider Business Mailing Address
First Line	:	13009 PEREGRINE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5426
Country	:	US
Telephone Number	:	405-703-0622
Fax Number	:	405-703-0622

Provider Business Practice Location Address
First Line	:	6701 BROADWAY EXT STE 210
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-8213
Country	:	US
Telephone Number	:	405-242-2242
Fax Number	:	405-286-1730

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

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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