Basic Information
| Provider Information | |||||||||
| NPI: | 1356705503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEBARTOLO | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MHR | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1624 CIMARRON PLZ | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740753467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053722202 | ||||||||
| FaxNumber: | 4054453780 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730715229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053605100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.