Healthcare Provider Details

I. General information

NPI: 1518604966
Provider Name (Legal Business Name): INTENTIONAL LIVES THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 DERBY RUN DR
EDMOND OK
73034-2625
US

IV. Provider business mailing address

3700 DERBY RUN DR
EDMOND OK
73034-2625
US

V. Phone/Fax

Practice location:
  • Phone: 405-590-7127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: RENE DAMAN
Title or Position: OWNER
Credential:
Phone: 405-590-7127