Basic Information
| Provider Information | |||||||||
| NPI: | 1730521683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OVERTON | ||||||||
| FirstName: | TYRIE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | CM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741204429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185601368 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Practice Location | |||||||||
| Address1: | 11740 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741291820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184379495 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2013 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.