Provider Demographics
NPI:1003273335
Name:DECKER, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26315 S 545 RD
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:OK
Mailing Address - Zip Code:74331-6497
Mailing Address - Country:US
Mailing Address - Phone:918-964-7025
Mailing Address - Fax:918-964-7024
Practice Address - Street 1:825 E 3RD ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7973
Practice Address - Country:US
Practice Address - Phone:918-964-7025
Practice Address - Fax:918-964-7024
Is Sole Proprietor?:No
Enumeration Date:2016-01-17
Last Update Date:2016-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2513OtherOKLAHOMA BOARD OF EXAMINERS SPEECH LANGUAGE PATHOLOGY AND AUDIOLOGY