Healthcare Provider Details

I. General information

NPI: 1295934297
Provider Name (Legal Business Name): ROGER A RUTH MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 S HARVARD AVE SUITE 100
TULSA OK
74135-2619
US

IV. Provider business mailing address

4300 S HARVARD AVE SUITE 100
TULSA OK
74135-2619
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-3170
  • Fax: 918-744-4432
Mailing address:
  • Phone: 918-585-3170
  • Fax: 918-744-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number471
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: