Healthcare Provider Details

I. General information

NPI: 1114355963
Provider Name (Legal Business Name): SANDRA KAY TWADDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 VETERANS AVE
TALIHINA OK
74571
US

IV. Provider business mailing address

13512 SW HIGHWAY 2
TUSKAHOMA OK
74574-1349
US

V. Phone/Fax

Practice location:
  • Phone: 918-567-3293
  • Fax: 918-567-3294
Mailing address:
  • Phone: 918-448-3330
  • Fax: 918-567-2081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: