=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124187992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER PARKS DEVELOPMENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5512 S LEWIS AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74105-7140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-747-1600
-----------------------------------------------------
Fax | 918-749-2774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5403 E 35TH ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-798-0779
-----------------------------------------------------
Fax | 918-583-1398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOW GREG MCCARTY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 918-798-0779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 644
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------