Healthcare Provider Details

I. General information

NPI: 1942977368
Provider Name (Legal Business Name): TALEASHA HARVEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 S MAIN ST
GROVE OK
74344-2800
US

IV. Provider business mailing address

PO BOX 721018
NORMAN OK
73070-4786
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-9883
  • Fax:
Mailing address:
  • Phone: 918-622-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3457
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: