Provider Demographics
NPI:1760919310
Name:FUNCTIONALITY THERAPY SERVICES PLLC
Entity Type:Organization
Organization Name:FUNCTIONALITY THERAPY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:OGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:580-220-7786
Mailing Address - Street 1:1000 ROCKFORD CT
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-3408
Mailing Address - Country:US
Mailing Address - Phone:580-220-7786
Mailing Address - Fax:
Practice Address - Street 1:10 W MAIN ST STE 218A
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6515
Practice Address - Country:US
Practice Address - Phone:580-220-7786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-17-25192103K00000X
OK3713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty