Basic Information
Provider Information | |||||||||
NPI: | 1437750734 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUZLJAKOVICH | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | LEAH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 W HOUSTON ST STE B | ||||||||
Address2: |   | ||||||||
City: | BROKEN ARROW | ||||||||
State: | OK | ||||||||
PostalCode: | 740123519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9182591888 | ||||||||
FaxNumber: | 9182513725 | ||||||||
Practice Location | |||||||||
Address1: | 536 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MUSKOGEE | ||||||||
State: | OK | ||||||||
PostalCode: | 744016345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186838555 | ||||||||
FaxNumber: | 9186838552 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2020 | ||||||||
LastUpdateDate: | 03/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 5908 | OK | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | 5908 | 01 | OK | STATE LICENSE | OTHER | 200951460A | 05 | OK |   | MEDICAID |