Basic Information
| Provider Information | |||||||||
| NPI: | 1235436007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMINE | ||||||||
| FirstName: | DARLA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 W MEMORIAL RD | ||||||||
| Address2: | 2-D | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731422029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053062095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2220 N CLASSEN BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731065809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055281748 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 919 | OK | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 4839 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200359107A | 05 | OK | MEDICAID |