=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780943738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA KAY NORBURY BSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2012
-----------------------------------------------------
Last Update Date | 05/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 DEWEY AVE STE 2
-----------------------------------------------------
City | POTEAU
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74953-4224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-917-3771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 SEQUOYAH ST
-----------------------------------------------------
City | TALIHINA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-917-3771
-----------------------------------------------------
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 |
-----------------------------------------------------