Healthcare Provider Details

I. General information

NPI: 1548096324
Provider Name (Legal Business Name): AUSTIN DIWIGHT RALSTIN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 WALL ST STE 100
NORMAN OK
73069-6360
US

IV. Provider business mailing address

521 N BROAD ST
GUTHRIE OK
73044-3324
US

V. Phone/Fax

Practice location:
  • Phone: 405-579-7560
  • Fax: 405-579-7563
Mailing address:
  • Phone: 405-757-1793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: