Healthcare Provider Details

I. General information

NPI: 1912043860
Provider Name (Legal Business Name): FAUST BIANCO JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7146 S BRADEN AVE STE. 500
TULSA OK
74136-6371
US

IV. Provider business mailing address

1761 E 31ST ST
TULSA OK
74105-2201
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-6165
  • Fax: 918-488-8021
Mailing address:
  • Phone: 918-746-0794
  • Fax: 918-746-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number754
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number579
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number754
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number579
License Number StateHI
# 5
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number754
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number579
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: