Basic Information
| Provider Information | |||||||||
| NPI: | 1013553163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAVERS | ||||||||
| FirstName: | MIRISSA | ||||||||
| MiddleName: | JOY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 10TH ST STE 211 | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738013156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802568615 | ||||||||
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| Practice Location | |||||||||
| Address1: | 193461 E. COUNTY RD. 304 | ||||||||
| Address2: | |||||||||
| City: | FORT SUPPLY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5807662311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2019 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.