Healthcare Provider Details

I. General information

NPI: 1578081634
Provider Name (Legal Business Name): 40:31 REHAB & WELLNESS, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 N YORK ST STE H
MUSKOGEE OK
74403-1442
US

IV. Provider business mailing address

1805 N YORK ST STE H
MUSKOGEE OK
74403-1442
US

V. Phone/Fax

Practice location:
  • Phone: 918-912-2796
  • Fax: 918-513-5808
Mailing address:
  • Phone: 918-912-2796
  • Fax: 918-513-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2138
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TARA MICHELLE OTTENBACHER
Title or Position: OWNER
Credential: OTR/L
Phone: 580-982-8316