Provider Demographics
NPI:1376628164
Name:SCOTT, BONNIE JOY (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:JOY
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:JOY
Other - Last Name:TARALDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1205 W OSAGE DR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2142
Mailing Address - Country:US
Mailing Address - Phone:405-372-0734
Mailing Address - Fax:775-667-7677
Practice Address - Street 1:215 W MCELROY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3537
Practice Address - Country:US
Practice Address - Phone:405-372-5292
Practice Address - Fax:775-667-7677
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100841720AMedicaid
OK100841720CMedicaid
OK100841720BMedicaid
OK100841720DMedicaid