Healthcare Provider Details

I. General information

NPI: 1255053906
Provider Name (Legal Business Name): PIVOTAL PATHWAYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19021 E CHOKEBERRY ST
OWASSO OK
74055-0037
US

IV. Provider business mailing address

PO BOX 754
OWASSO OK
74055-0754
US

V. Phone/Fax

Practice location:
  • Phone: 918-972-1088
  • Fax: 918-921-8143
Mailing address:
  • Phone: 918-972-1088
  • Fax: 918-921-8143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN M GARY
Title or Position: OWNER
Credential: RN, BCBA, LBA
Phone: 918-972-1088