1578569018 NPI number — MISS SANDRA WAGNER RYDEN MSW, LCSW,

Table of content: MISS SANDRA WAGNER RYDEN MSW, LCSW, (NPI 1578569018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578569018 NPI number — MISS SANDRA WAGNER RYDEN MSW, LCSW,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYDEN
Provider First Name:
SANDRA
Provider Middle Name:
WAGNER
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW,
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:
1578569018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5574
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-5574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-360-7165
Provider Business Mailing Address Fax Number:
405-360-7165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 W LINDSEY ST STE C212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73069-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-360-7165
Provider Business Practice Location Address Fax Number:
405-360-7165
Provider Enumeration Date:
06/21/2005

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: 1041C0700X , with the licence number:  0674 , 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: 0007391110 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100707540A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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