Basic Information
| Provider Information | |||||||||
| NPI: | 1508043548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUGHTON | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7912 E 31ST CT | ||||||||
| Address2: | STE 210 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741451315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924477 | ||||||||
| FaxNumber: | 9183924465 | ||||||||
| Practice Location | |||||||||
| Address1: | 9001 S 101ST EAST AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182946845 | ||||||||
| FaxNumber: | 9182946853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1511 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 200194410A | 05 | OK | MEDICAID |