Provider Demographics
NPI:1235218454
Name:DECKARD, TERESA KAY (OTR L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:KAY
Last Name:DECKARD
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17599 S HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-0801
Mailing Address - Country:US
Mailing Address - Phone:918-342-8161
Mailing Address - Fax:918-341-4245
Practice Address - Street 1:17599 S HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-0801
Practice Address - Country:US
Practice Address - Phone:918-342-8161
Practice Address - Fax:918-341-4245
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT347225X00000X, 225XH1200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100639930AMedicaid