Healthcare Provider Details

I. General information

NPI: 1619417193
Provider Name (Legal Business Name): OPAL SPEECH CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 OKLAHOMA BLVD
ALVA OK
73717-2631
US

IV. Provider business mailing address

921 OKLAHOMA BLVD STE A
ALVA OK
73717-2631
US

V. Phone/Fax

Practice location:
  • Phone: 580-220-7461
  • Fax: 580-327-0091
Mailing address:
  • Phone: 580-220-7461
  • Fax: 580-327-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2325
License Number StateOK

VIII. Authorized Official

Name: TRILBY D. SCHMIDT
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S. CCC-SLP
Phone: 580-327-0091