| NPI | 1982366605 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRACY VAN SLYKE Manager, Provider Enrollment 918-809-2411 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2084B0040X Psychiatry & Neurology, Behavioral Neurology & Neuropsychiatry |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical |
| Enumeration Date | 2021-10-11 |
| Last Update Date | 2021-10-11 |