Provider Demographics
NPI:1699974584
Name:PROFIT, IRVIN DWAYNE (LADC U/S)
Entity type:Individual
Prefix:
First Name:IRVIN
Middle Name:DWAYNE
Last Name:PROFIT
Suffix:
Gender:M
Credentials:LADC U/S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 S. LEWIS, STE 219
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105
Mailing Address - Country:US
Mailing Address - Phone:918-832-7763
Mailing Address - Fax:918-292-8250
Practice Address - Street 1:5319 S. LEWIS, STE 219
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-832-7763
Practice Address - Fax:918-292-8250
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)