Basic Information
Provider Information | |||||||||
NPI: | 1376928416 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSENHAMER | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | RENAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW U/S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 907 W CADDO ST | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OK | ||||||||
PostalCode: | 740204201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183085511 | ||||||||
FaxNumber: | 9182052701 | ||||||||
Practice Location | |||||||||
Address1: | 907 W CADDO ST | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OK | ||||||||
PostalCode: | 740204201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183085511 | ||||||||
FaxNumber: | 9182052701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2015 | ||||||||
LastUpdateDate: | 02/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6992 | OK | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.