=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104113083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE DIANE GOLDMAN BHR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2011
-----------------------------------------------------
Last Update Date | 06/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 N CLARENCE NASH BLVD
-----------------------------------------------------
City | WATONGA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73772-3636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-623-5433
-----------------------------------------------------
Fax | 580-623-2409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 E PROCTOR AVE APT 2
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73096-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-819-3200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------