Basic Information
| Provider Information | |||||||||
| NPI: | 1740467448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | MYLINDA | ||||||||
| MiddleName: | CAROL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 125 | ||||||||
| Address2: | |||||||||
| City: | COLONY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059297320 | ||||||||
| FaxNumber: | 5803230828 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 N. 31ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803236021 | ||||||||
| FaxNumber: | 5803230828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 01/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.