Healthcare Provider Details

I. General information

NPI: 1801259692
Provider Name (Legal Business Name): OUTSIDE THE BOX SPEECH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19001 S 369TH WEST AVE
BRISTOW OK
74010-2067
US

IV. Provider business mailing address

19001 S 369TH WEST AVE
BRISTOW OK
74010-2067
US

V. Phone/Fax

Practice location:
  • Phone: 405-255-0642
  • Fax:
Mailing address:
  • Phone: 405-255-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number3498
License Number StateOK

VIII. Authorized Official

Name: JENNIFER N KEMP
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: MS, CCC-SLP
Phone: 405-255-0642