Basic Information
Provider Information | |||||||||
NPI: | 1285776963 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARMETER | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAFON | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6804 E FOREST RIDGE BLVD | ||||||||
Address2: |   | ||||||||
City: | BROKEN ARROW | ||||||||
State: | OK | ||||||||
PostalCode: | 740146927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185196569 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 619 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MUSKOGEE | ||||||||
State: | OK | ||||||||
PostalCode: | 744014431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186828407 | ||||||||
FaxNumber: | 9186870976 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2007 | ||||||||
LastUpdateDate: | 05/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 200366200A | 05 | OK |   | MEDICAID |