Healthcare Provider Details

I. General information

NPI: 1033052295
Provider Name (Legal Business Name): MS. REBECKA RAYN PURDOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W QUEENS ST
BROKEN ARROW OK
74012-1767
US

IV. Provider business mailing address

721 W QUEENS ST
BROKEN ARROW OK
74012-1767
US

V. Phone/Fax

Practice location:
  • Phone: 539-367-1534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: