Healthcare Provider Details

I. General information

NPI: 1366445488
Provider Name (Legal Business Name): DERRIEN RELYEA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 N SANTA FE AVE STE B
OKLAHOMA CITY OK
73116-9126
US

IV. Provider business mailing address

6400 N SANTA FE AVE STE B
OKLAHOMA CITY OK
73116-9126
US

V. Phone/Fax

Practice location:
  • Phone: 405-840-2903
  • Fax: 405-840-3256
Mailing address:
  • Phone: 405-840-2903
  • Fax: 405-840-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2774
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: