Healthcare Provider Details

I. General information

NPI: 1376587139
Provider Name (Legal Business Name): TULSA FAMILY DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 S HARVARD AVE STE 200C
TULSA OK
74135-2925
US

IV. Provider business mailing address

4520 S HARVARD AVE STE 200C
TULSA OK
74135-2925
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-3224
  • Fax: 918-743-9623
Mailing address:
  • Phone: 918-743-3224
  • Fax: 918-743-9623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ELISA M WOODHEAD
Title or Position: CREDENTIALING MANAGER
Credential: CMA (AAMA)
Phone: 918-299-8232