Healthcare Provider Details

I. General information

NPI: 1114463072
Provider Name (Legal Business Name): DAVE SANFORD KERBY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 SW 4TH ST
MOORE OK
73160-2405
US

IV. Provider business mailing address

1044 SW 4TH ST
MOORE OK
73160-2405
US

V. Phone/Fax

Practice location:
  • Phone: 405-735-6333
  • Fax: 405-735-6629
Mailing address:
  • Phone: 405-735-6333
  • Fax: 405-735-6629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1277
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: