Healthcare Provider Details

I. General information

NPI: 1912671686
Provider Name (Legal Business Name): TATIANA CORBETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 NW GRAND BLVD
OKLAHOMA CITY OK
73118-6000
US

IV. Provider business mailing address

1012 NW GRAND BLVD
OKLAHOMA CITY OK
73118-6000
US

V. Phone/Fax

Practice location:
  • Phone: 405-594-8336
  • Fax:
Mailing address:
  • Phone: 405-594-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-178986
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: