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General NPI Number Information
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NPI Number | 1578081634
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Entity Type | Organization
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Legal Business Name | 40:31 REHAB & WELLNESS, PLLC.
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Dates
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Enumeration Date | 09/08/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 251 W 70TH ST S
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City | MUSKOGEE
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State | OK
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Zip | 74401-8924
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Country | US
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Telephone | 580-982-8316
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Fax | 918-910-3598
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Provider Business Mailing Address
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Address Line | 251 W 70TH ST S
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City | MUSKOGEE
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State | OK
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Zip | 74401-8924
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Country | US
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Telephone | 580-982-8316
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Fax | 918-910-3598
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Authorized Official
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Title or Position | OWNER
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Name | TARA MICHELLE LOONEY
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Credential | OTR/L
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Telephone | 580-982-8316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2138
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License Number State | OK
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