Healthcare Provider Details

I. General information

NPI: 1760744718
Provider Name (Legal Business Name): PEDIATRIC NEUROPSYCHOLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 NW 56TH ST SUITE 305
OKLAHOMA CITY OK
73112-4479
US

IV. Provider business mailing address

3330 NW 56TH ST SUITE 305
OKLAHOMA CITY OK
73112-4479
US

V. Phone/Fax

Practice location:
  • Phone: 405-713-7065
  • Fax: 405-713-7064
Mailing address:
  • Phone: 405-713-7065
  • Fax: 405-713-7064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number944
License Number StateOK

VIII. Authorized Official

Name: DR. LORI HOLMQUIST-DAY
Title or Position: PEDIATRIC NEUROPSYCHOLOGIST
Credential: PHD
Phone: 405-713-7065