Healthcare Provider Details

I. General information

NPI: 1922355189
Provider Name (Legal Business Name): EMPOWERING LIFE THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

783 COUNTY STREET 2981
TUTTLE OK
73089-1109
US

IV. Provider business mailing address

783 COUNTY STREET 2981
TUTTLE OK
73089-1109
US

V. Phone/Fax

Practice location:
  • Phone: 405-694-7703
  • Fax: 866-721-5328
Mailing address:
  • Phone: 405-694-7703
  • Fax: 866-721-5328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1721
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200341030B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MS. SAMANTHA PRATER
Title or Position: OWNER/DIRECTOR
Credential: OTR/L
Phone: 405-694-7703