1760264105 NPI number — MS. OLIVIA CHASE PERALTA OTR/L

Table of content: MS. OLIVIA CHASE PERALTA OTR/L (NPI 1760264105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760264105 NPI number — MS. OLIVIA CHASE PERALTA OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERALTA
Provider First Name:
OLIVIA
Provider Middle Name:
CHASE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
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:
1760264105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 S SWEET GUM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-4502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-629-5508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4619 S HARVARD AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
539-867-3151
Provider Business Practice Location Address Fax Number:
918-513-5808
Provider Enumeration Date:
10/19/2023

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: 225XP0200X , with the licence number:  5849 , 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)





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