Provider Demographics
NPI:1114790821
Name:PAUL, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HOPPE BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2318
Mailing Address - Country:US
Mailing Address - Phone:405-857-8280
Mailing Address - Fax:405-857-8489
Practice Address - Street 1:1300 HOPPE BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2318
Practice Address - Country:US
Practice Address - Phone:405-857-8280
Practice Address - Fax:405-857-8489
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician