Basic Information
| Provider Information | |||||||||
| NPI: | 1629591862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONVERSE | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2617 GENERAL PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731076437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058582700 | ||||||||
| FaxNumber: | 4058582810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2617 GENERAL PERSHING BLVD. | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058582700 | ||||||||
| FaxNumber: | 4058582810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.