Healthcare Provider Details

I. General information

NPI: 1942212097
Provider Name (Legal Business Name): MICHAEL STEPHEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD #801
OKLAHOMA CITY OK
73120-9350
US

IV. Provider business mailing address

4200 W MEMORIAL RD #801
OKLAHOMA CITY OK
73120-9350
US

V. Phone/Fax

Practice location:
  • Phone: 405-858-8777
  • Fax: 405-858-8777
Mailing address:
  • Phone: 405-858-8777
  • Fax: 405-858-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number540
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number540
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number540
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number540
License Number StateOK
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number540
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: