Healthcare Provider Details

I. General information

NPI: 1609790260
Provider Name (Legal Business Name): TESA ALICE PENROD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W ELM
TUTTLE OK
73089-9033
US

IV. Provider business mailing address

105 W ELM
TUTTLE OK
73089-9033
US

V. Phone/Fax

Practice location:
  • Phone: 405-882-6506
  • Fax:
Mailing address:
  • Phone: 405-882-6506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: