Healthcare Provider Details

I. General information

NPI: 1912132358
Provider Name (Legal Business Name): SPECTRUM THERAPY CENTER, CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S BOULEVARD ST SUITE 126
EDMOND OK
73034-3878
US

IV. Provider business mailing address

301 S BOULEVARD ST SUITE 126
EDMOND OK
73034-3878
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-6765
  • Fax: 405-285-5403
Mailing address:
  • Phone: 405-285-6765
  • Fax: 405-285-5403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANNA PERSUN
Title or Position: PRESIDENT/ OCCUPATIONAL THERAPIST
Credential: OTR
Phone: 405-285-6765