Basic Information
| Provider Information | |||||||||
| NPI: | 1366814212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICKETTS | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7738 N OWASSO EXPWY | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189284255 | ||||||||
| FaxNumber: | 9189284258 | ||||||||
| Practice Location | |||||||||
| Address1: | STRIDES PEDIATRIC THERAPY | ||||||||
| Address2: | 7738 N OWASSO EXPWY | ||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189284255 | ||||||||
| FaxNumber: | 9189284258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2015 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1617 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200952900A | 05 | OK | MEDICAID |