Healthcare Provider Details

I. General information

NPI: 1720347776
Provider Name (Legal Business Name): TRACEY BOWIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N CLASSEN BLVD
OKLAHOMA CITY OK
73118-4627
US

IV. Provider business mailing address

2316 TOWERS CT
OKLAHOMA CITY OK
73111-1652
US

V. Phone/Fax

Practice location:
  • Phone: 405-417-8459
  • Fax:
Mailing address:
  • Phone: 405-424-4290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number081340659
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: