Healthcare Provider Details

I. General information

NPI: 1952747370
Provider Name (Legal Business Name): SOPHIA EMMA THUNDU M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 W 55TH PL SUITE 119
TULSA OK
74107-9108
US

IV. Provider business mailing address

PO BOX 702504
TULSA OK
74170-2504
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-9996
  • Fax: 800-260-7966
Mailing address:
  • Phone: 918-486-9996
  • Fax: 800-260-7966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCANDIDATE
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: