Basic Information
| Provider Information | |||||||||
| NPI: | 1659381812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 S. CHOCKTAW | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052220622 | ||||||||
| FaxNumber: | 4052249532 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 S. CHOCKTAW AVE. | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052220622 | ||||||||
| FaxNumber: | 4052249532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YP2500X | 3600 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.