Provider Demographics
NPI:1043854706
Name:FREEBORN DYSPHAGIA ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FREEBORN DYSPHAGIA ASSOCIATES, LLC
Other - Org Name:HEART OF OKLAHOMA CENTER FOR SWALLOW & SPEECH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:ALYCIA
Authorized Official - Last Name:FREEBORN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:405-609-4618
Mailing Address - Street 1:18550 144TH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OK
Mailing Address - Zip Code:73051-6803
Mailing Address - Country:US
Mailing Address - Phone:405-766-1238
Mailing Address - Fax:405-310-0679
Practice Address - Street 1:120 S LESTER LANE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-5451
Practice Address - Country:US
Practice Address - Phone:405-766-1238
Practice Address - Fax:405-310-0679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14002787OtherASHA
CA19013OtherCALIFORNIA STATE LICENSE
OK200952980AMedicaid
OK4171OtherOKLAHOMA SLP