Healthcare Provider Details

I. General information

NPI: 1780491894
Provider Name (Legal Business Name): PEDIATRIC PATHWAYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 5TH ST STE 10
CHICKASHA OK
73018-2405
US

IV. Provider business mailing address

209 PLEASANT LN
CHICKASHA OK
73018-7727
US

V. Phone/Fax

Practice location:
  • Phone: 405-213-3324
  • Fax:
Mailing address:
  • Phone: 405-213-3324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIRA DERR
Title or Position: OWNER/SLP
Credential: MS, CCC-SLP
Phone: 405-213-3324