Healthcare Provider Details

I. General information

NPI: 1093840589
Provider Name (Legal Business Name): TIM RJ PASSMORE ED.D., CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3124 W 24TH AVE
STILLWATER OK
74074-2101
US

IV. Provider business mailing address

3124 W 24TH AVE
STILLWATER OK
74074-2101
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-1811
  • Fax: 405-744-6507
Mailing address:
  • Phone: 405-744-1811
  • Fax: 405-744-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: