Provider Demographics
NPI:1093838971
Name:THERAPYTIME PEDIATRICS
Entity Type:Organization
Organization Name:THERAPYTIME PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:DECELLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:918-712-1868
Mailing Address - Street 1:4157 S HARVARD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2606
Mailing Address - Country:US
Mailing Address - Phone:918-712-7868
Mailing Address - Fax:918-749-2901
Practice Address - Street 1:4157 S HARVARD AVE STE 101
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2606
Practice Address - Country:US
Practice Address - Phone:918-712-7868
Practice Address - Fax:918-749-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1780225100000X
OKPT2077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty