Basic Information
| Provider Information | |||||||||
| NPI: | 1467712968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8992 N 490 RD | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184570044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15481 N JARVIS RD | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184565131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.