1063567147 NPI number — CREATIVE SPEECH THERAPY

Table of content: (NPI 1063567147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063567147 NPI number — CREATIVE SPEECH THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE SPEECH THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1063567147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 471674
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74147-1674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-734-7115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2615 E 138TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIXBY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74008-3878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-734-7115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COVEY
Authorized Official First Name:
TAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
SPEECH PATHOLOGIST
Authorized Official Telephone Number:
918-743-3530

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  2603 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 697658 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 005308803873 . This is a "BCBSOK" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 7392760 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100677120A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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