Basic Information
Provider Information | |||||||||
NPI: | 1366793747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JULIAN | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1222 10TH ST | ||||||||
Address2: | SUITE 211 | ||||||||
City: | WOODWARD | ||||||||
State: | OK | ||||||||
PostalCode: | 738013156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802568615 | ||||||||
FaxNumber: | 5802568609 | ||||||||
Practice Location | |||||||||
Address1: | 5120 HWY 54 NE | ||||||||
Address2: |   | ||||||||
City: | GUYMON | ||||||||
State: | OK | ||||||||
PostalCode: | 739421247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5803385851 | ||||||||
FaxNumber: | 5803386022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2012 | ||||||||
LastUpdateDate: | 09/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 4396 | OK | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.