Provider Demographics
NPI:1629237946
Name:TABB, ROLAND V (BHRS)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:V
Last Name:TABB
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2239
Mailing Address - Country:US
Mailing Address - Phone:405-601-2307
Mailing Address - Fax:405-601-3317
Practice Address - Street 1:625 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2239
Practice Address - Country:US
Practice Address - Phone:405-601-2307
Practice Address - Fax:405-601-3317
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200077440Medicaid