Basic Information
| Provider Information | |||||||||
| NPI: | 1174941512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT CHANGES RESOURCE CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720997 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731720997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056040496 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 NW 47TH ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731186400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056040496 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHOUN | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4056040496 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTRL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT223 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.