Healthcare Provider Details

I. General information

NPI: 1700994878
Provider Name (Legal Business Name): OKLAHOMA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

042 MURRAY
STILLWATER OK
74078
US

IV. Provider business mailing address

042 MURRAY
STILLWATER OK
74078-5062
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-6021
  • Fax: 405-744-8070
Mailing address:
  • Phone: 405-744-6021
  • Fax: 405-744-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateOK

VIII. Authorized Official

Name: DONITA R TEFFT
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 405-744-8939