=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124837224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN RODEBUSH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12400 S HIWASSEE RD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73165-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-833-1013
-----------------------------------------------------
Fax | 405-931-0016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 HISEL RD
-----------------------------------------------------
City | DEL CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73115-4533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-589-0914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2558
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------