1073175832 NPI number — MS. JODY LYNN DALLIS BSW

Table of content: MS. JODY LYNN DALLIS BSW (NPI 1073175832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073175832 NPI number — MS. JODY LYNN DALLIS BSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALLIS
Provider First Name:
JODY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073175832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14204 N 480 RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74464-0338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-708-5357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TENKILLER BEHAVIORAL SERVICES
Provider Second Line Business Practice Location Address:
27753 S. WELLING RD
Provider Business Practice Location Address City Name:
WELLING
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-708-5357
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)