MEDICARE: MS. LISA DE AMBER KOMAHCHEET LADC

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	101Y00000X	Counselor	#588	OK

General Provider Information

NPI Number	:	1972829901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA DE AMBER KOMAHCHEET LADC

Provider Business Mailing Address
First Line	:	3212 SW 104TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7800
Country	:	US
Telephone Number	:	405-213-3700
Fax Number	:	405-208-4574

Provider Business Practice Location Address
First Line	:	3212 SW 104TH TER
Second Line	:	2915 N CLASSEN BLVD. SUITE 325
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7800
Country	:	US
Telephone Number	:	405-213-3700
Fax Number	:	405-208-4574

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

Provider Enumeration Date	:	04/15/2010
Last Update Date	:	04/15/2010

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