Basic Information
Provider Information | |||||||||
NPI: | 1982106837 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALKER SQUARE THERAPY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4334 NW EXPRESSWAY STE 187 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731161515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053553239 | ||||||||
FaxNumber: | 4052124270 | ||||||||
Practice Location | |||||||||
Address1: | 309 SW 59TH ST STE 305 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731098324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053553239 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2018 | ||||||||
LastUpdateDate: | 03/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: | EDWIN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4053553239 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.