Healthcare Provider Details

I. General information

NPI: 1114613973
Provider Name (Legal Business Name): TIMOTHY WAYNE FOREMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16414 W 760 RD
TAHLEQUAH OK
74464-1675
US

IV. Provider business mailing address

PO BOX 73
OAKS OK
74359-0073
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-9009
  • Fax:
Mailing address:
  • Phone: 918-907-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: