Healthcare Provider Details

I. General information

NPI: 1467769851
Provider Name (Legal Business Name): DIANA DAYL WOOLDRIDGE MHR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 S GARNETT RD STE 200 5550 S GARNETT, SUITE 200
TULSA OK
74146-6830
US

IV. Provider business mailing address

5550 S GARNETT RD STE 200 5550 S GARNETT, SUITE 200
TULSA OK
74146-6830
US

V. Phone/Fax

Practice location:
  • Phone: 918-665-2501
  • Fax: 918-665-2501
Mailing address:
  • Phone: 918-665-2501
  • Fax: 918-665-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: