Healthcare Provider Details

I. General information

NPI: 1659613016
Provider Name (Legal Business Name): TULSA BEHAVIORAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5272 S LEWIS AVE SUITE 220
TULSA OK
74105-6544
US

IV. Provider business mailing address

5272 S LEWIS AVE SUITE 220
TULSA OK
74105-6544
US

V. Phone/Fax

Practice location:
  • Phone: 918-938-7701
  • Fax: 918-938-7006
Mailing address:
  • Phone: 918-938-7701
  • Fax: 918-938-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number10770
License Number StateOK

VIII. Authorized Official

Name: WALTER JAY EXON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 918-938-7701