MEDICARE: DERELL JOVAN SPIRES

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
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1952600785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERELL JOVAN SPIRES

Provider Business Mailing Address
First Line	:	9242 N MACARTHUR BLVD APT A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-2451
Country	:	US
Telephone Number	:	870-995-0919
Fax Number	:

Provider Business Practice Location Address
First Line	:	9242 NORTH MCARTHUR BLVD APT A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132
Country	:	US
Telephone Number	:	870-995-0919
Fax Number	:

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

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	03/18/2011

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