=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013387703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TALITHA GLORIA GLOSEMEYER OT/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6127 S JOPLIN AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-503-6825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 W SHAWNEE ST
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74401-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-683-0040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT640
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Occupational Therapist
-----------------------------------------------------
License Number | OT640
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XH1300X
-----------------------------------------------------
Taxonomy Name | Human Factors Occupational Therapist
-----------------------------------------------------
License Number | OT640
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225XP0019X
-----------------------------------------------------
Taxonomy Name | Physical Rehabilitation Occupational Therapist
-----------------------------------------------------
License Number | OT640
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------