Healthcare Provider Details

I. General information

NPI: 1790030492
Provider Name (Legal Business Name): STACEY R OGDEN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 10TH AVE NW
ARDMORE OK
73401-4025
US

IV. Provider business mailing address

1405 4TH AVE NW # 296
ARDMORE OK
73401-2708
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-5566
  • Fax: 580-226-5567
Mailing address:
  • Phone: 580-226-5566
  • Fax: 580-226-5567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License Number3713
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: