Healthcare Provider Details

I. General information

NPI: 1306341433
Provider Name (Legal Business Name): YSELDA TAMI YANEZ-SOUTHARD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/16/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH STREET AMHC 3G100
OKLAHOMA CITY OK
73014
US

IV. Provider business mailing address

921 NE 13TH STREET AMHC 3G100
OKLAHOMA CITY OK
73014
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-5183
  • Fax:
Mailing address:
  • Phone: 405-456-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: