Basic Information
| Provider Information | |||||||||
| NPI: | 1669703690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELEVATE PEDIATRIC THERAPIES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1071 W BLUE STARR DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740172868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183414343 | ||||||||
| FaxNumber: | 9183418687 | ||||||||
| Practice Location | |||||||||
| Address1: | 1071 W. BLUE STARR DRIVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740175567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183423800 | ||||||||
| FaxNumber: | 9183423900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2010 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | RYLEE | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9183414343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 68 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | 2016 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | 1823 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 442782197001 | 01 | OK | BLUECROSS AND BLUESHIELDS | OTHER | 100748010B | 05 | OK | MEDICAID | 9069034 | 01 | OK | PHCS / MULTIPLAN | OTHER | 7866001 | 01 | OK | AETNA | OTHER | 9934451 | 01 | OK | CIGNA | OTHER |