Healthcare Provider Details

I. General information

NPI: 1114438785
Provider Name (Legal Business Name): MIND THE GAP NEUROPSYCHOLOGY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10621 HASKELL LN
OKLAHOMA CITY OK
73162-8212
US

IV. Provider business mailing address

10621 HASKELL LN
OKLAHOMA CITY OK
73162-8212
US

V. Phone/Fax

Practice location:
  • Phone: 602-625-1943
  • Fax:
Mailing address:
  • Phone: 602-625-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1087
License Number StateOK

VIII. Authorized Official

Name: MELANIE TALLEY
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 602-625-1943