Healthcare Provider Details

I. General information

NPI: 1629641402
Provider Name (Legal Business Name): MADISON CHASE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 E 31ST ST
TULSA OK
74135-5018
US

IV. Provider business mailing address

18440 E CROOKED OAK DR
OWASSO OK
74055-5053
US

V. Phone/Fax

Practice location:
  • Phone: 918-600-3100
  • Fax: 918-560-1399
Mailing address:
  • Phone: 918-691-8289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: