Basic Information
Provider Information | |||||||||
NPI: | 1659400281 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAQUOI | ||||||||
FirstName: | ALICE | ||||||||
MiddleName: | GBANAH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW UND SUP FOR LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARR | ||||||||
OtherFirstName: | ALICE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 650 S PEORIA | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741204429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185879471 | ||||||||
FaxNumber: | 9185600137 | ||||||||
Practice Location | |||||||||
Address1: | 2325 S HARVARD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741143300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187124301 | ||||||||
FaxNumber: | 9187123409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.