Healthcare Provider Details

I. General information

NPI: 1346939493
Provider Name (Legal Business Name): TIA KIRSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 N COUNCIL RD BLDG E
BETHANY OK
73008-3131
US

IV. Provider business mailing address

11901 CASEY DR
YUKON OK
73099-9394
US

V. Phone/Fax

Practice location:
  • Phone: 405-208-4469
  • Fax:
Mailing address:
  • Phone: 405-208-4469
  • Fax: 405-208-4472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12414
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: