Provider Demographics
NPI:1578081634
Name:40:31 REHAB & WELLNESS, PLLC.
Entity Type:Organization
Organization Name:40:31 REHAB & WELLNESS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:580-982-8316
Mailing Address - Street 1:251 W 70TH ST S
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-8924
Mailing Address - Country:US
Mailing Address - Phone:580-982-8316
Mailing Address - Fax:918-910-3598
Practice Address - Street 1:251 W 70TH ST S
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-8924
Practice Address - Country:US
Practice Address - Phone:580-982-8316
Practice Address - Fax:918-910-3598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2138225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty