Healthcare Provider Details

I. General information

NPI: 1023695756
Provider Name (Legal Business Name): SYLVIA SHALOM OTIS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SYLVIA SHALOM RUEB

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7306 S YALE AVE
TULSA OK
74136-7027
US

IV. Provider business mailing address

7107 S YALE AVE # 161
TULSA OK
74136-6308
US

V. Phone/Fax

Practice location:
  • Phone: 918-280-0090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-45064
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: