1164669149 NPI number — LATIA R PARKER LADC, LPC

Table of content: LATIA R PARKER LADC, LPC (NPI 1164669149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164669149 NPI number — LATIA R PARKER LADC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARKER
Provider First Name:
LATIA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164669149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W HOBSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAPULPA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74066-3926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-902-5348
Provider Business Mailing Address Fax Number:
918-224-6837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2508 E 71ST ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74136-5572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-794-6570
Provider Business Practice Location Address Fax Number:
918-340-5189
Provider Enumeration Date:
01/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  659 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3343 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200232480A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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