Basic Information
| Provider Information | |||||||||
| NPI: | 1982935326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YORK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.A.D.C. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 619 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186828407 | ||||||||
| FaxNumber: | 9186870976 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186828407 | ||||||||
| FaxNumber: | 9186870976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 200519870A | 05 | OK | MEDICAID |