Provider Demographics
NPI:1578114591
Name:OK PEDS PEDIATRIC THERAPY SERVICES
Entity Type:Organization
Organization Name:OK PEDS PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SEIRRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWELLING
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP/L
Authorized Official - Phone:405-659-6390
Mailing Address - Street 1:7301 S HARRAH RD
Mailing Address - Street 2:
Mailing Address - City:NEWALLA
Mailing Address - State:OK
Mailing Address - Zip Code:74857-7912
Mailing Address - Country:US
Mailing Address - Phone:405-659-6390
Mailing Address - Fax:855-933-0242
Practice Address - Street 1:7301 S HARRAH RD
Practice Address - Street 2:
Practice Address - City:NEWALLA
Practice Address - State:OK
Practice Address - Zip Code:74857-7912
Practice Address - Country:US
Practice Address - Phone:405-659-6390
Practice Address - Fax:855-933-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200769930AMedicaid