Healthcare Provider Details

I. General information

NPI: 1285050831
Provider Name (Legal Business Name): MS. REGINA KAY TISDALE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W APACHE ST
TULSA OK
74127-2023
US

IV. Provider business mailing address

3600 W. PACHE ST.
TULSA OK
74127-2023
US

V. Phone/Fax

Practice location:
  • Phone: 918-284-4837
  • Fax:
Mailing address:
  • Phone: 918-284-4837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: