Healthcare Provider Details

I. General information

NPI: 1073434064
Provider Name (Legal Business Name): FULL CIRCLE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 CINDY ST
FREDERICK OK
73542-1604
US

IV. Provider business mailing address

1408 CINDY ST
FREDERICK OK
73542-1604
US

V. Phone/Fax

Practice location:
  • Phone: 580-305-2988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KENNEDY ANN WAMBOLT
Title or Position: OTR/OWNER
Credential: OTR
Phone: 580-305-2988