Healthcare Provider Details

I. General information

NPI: 1699506725
Provider Name (Legal Business Name): BRAINSTORM PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S MUSKOGEE AVE
TAHLEQUAH OK
74464-3658
US

IV. Provider business mailing address

3871 LEXINGTON AVE
TAHLEQUAH OK
74464-5056
US

V. Phone/Fax

Practice location:
  • Phone: 918-216-0162
  • Fax:
Mailing address:
  • Phone: 918-808-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
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: DR. MARTI VELEZ
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 918-808-9084