Basic Information
| Provider Information | |||||||||
| NPI: | 1568632776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TULSA CENTER FOR CHILD PSYCHOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6966 S UTICA AVE | ||||||||
| Address2: | STE 225 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184926333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5110 S YALE AVE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741357401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187797637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALTON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187797637 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 508 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.