Healthcare Provider Details

I. General information

NPI: 1306151451
Provider Name (Legal Business Name): VICTORIA S WALDRUP MSH, BHRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 N FLORENCE AVE STE D
CLAREMORE OK
74017-4294
US

IV. Provider business mailing address

3100 S ELM PL SUITE B
BROKEN ARROW OK
74012-7950
US

V. Phone/Fax

Practice location:
  • Phone: 918-341-0087
  • Fax: 918-341-0081
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: