Basic Information
Provider Information
NPI: 1003140237
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DARITY
FirstName: MICHELE
MiddleName: CAROL
NamePrefix:  
NameSuffix:  
Credential: M.S.,CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 370 S SHAW RD
Address2:  
City: ATOKA
State: OK
PostalCode: 745255174
CountryCode: US
TelephoneNumber: 5805099125
FaxNumber: 5803268850
Practice Location
Address1: 1001 HERITAGE WAY
Address2:  
City: HUGO
State: OK
PostalCode: 74743
CountryCode: US
TelephoneNumber: 5805099125
FaxNumber: 5803268850
Other Information
ProviderEnumerationDate: 09/21/2009
LastUpdateDate: 09/21/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X3146OKY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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