Individual
IDA S KEMUNTO MAGATI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
626 N BROADWAY ST, MOORE, OK 73160-4814
(405) 588-7149
Mailing address
2424 ASHEBURY WAY, EDMOND, OK 73034-5855
(405) 588-7149
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
08/15/2017
Last updated
08/15/2017
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