Provider Demographics
NPI:1417968249
Name:NEURORESOURCES REHABILITATION SPECIALISTS, LLC
Entity Type:Organization
Organization Name:NEURORESOURCES REHABILITATION SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TISDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, MPH, ATP
Authorized Official - Phone:405-605-1466
Mailing Address - Street 1:PO BOX 12036
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-2036
Mailing Address - Country:US
Mailing Address - Phone:405-605-1466
Mailing Address - Fax:405-605-1467
Practice Address - Street 1:6108 NW 63RD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-7553
Practice Address - Country:US
Practice Address - Phone:405-605-1466
Practice Address - Fax:405-605-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100660200AMedicaid
OK100660200AMedicaid
OKQ46471Medicare UPIN