Healthcare Provider Details

I. General information

NPI: 1609051440
Provider Name (Legal Business Name): TANYA MATTEK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 NE 50TH ST
OKLAHOMA CITY OK
73141-9118
US

IV. Provider business mailing address

1124 CADDELL LN
NORMAN OK
73069-4541
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-6111
  • Fax:
Mailing address:
  • Phone: 405-447-4327
  • Fax: 405-447-4327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2865
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: