=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053681825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA A. VALTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2012
-----------------------------------------------------
Last Update Date | 01/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1222 N FLORENCE AVE STE A
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-4294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-341-0087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1818 W ASH ST
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-478-7872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------