Healthcare Provider Details

I. General information

NPI: 1699205930
Provider Name (Legal Business Name): CANDACE J HLADIK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CREEK VIEW CT
NEWCASTLE OK
73065-7202
US

IV. Provider business mailing address

3400 CREEK VIEW CT
NEWCASTLE OK
73065-7202
US

V. Phone/Fax

Practice location:
  • Phone: 405-496-9884
  • Fax:
Mailing address:
  • Phone: 405-496-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1792
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: