Healthcare Provider Details

I. General information

NPI: 1629308390
Provider Name (Legal Business Name): GLENDA D BOYLE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MAIN ST
HOMINY OK
74035-1031
US

IV. Provider business mailing address

210 COUNTY ROAD 3237
BARTLESVILLE OK
74003-7110
US

V. Phone/Fax

Practice location:
  • Phone: 918-885-4640
  • Fax:
Mailing address:
  • Phone: 918-336-4614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0816
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: