Basic Information
| Provider Information | |||||||||
| NPI: | 1669787768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTOINE | ||||||||
| FirstName: | GUY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANTOINE | ||||||||
| OtherFirstName: | LOUISE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 W OHIO | ||||||||
| Address2: | P.O. BOX # 284 | ||||||||
| City: | KIEFER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740414523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188122072 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1516 S BOSTON AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741194003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185616000 | ||||||||
| FaxNumber: | 9185616001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 08/12/2010 | ||||||||
| 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 | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.