Provider Demographics
NPI:1861859373
Name:MICHELINE WIJTENBURG PC INC
Entity Type:Organization
Organization Name:MICHELINE WIJTENBURG PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:405-292-1000
Mailing Address - Street 1:1225 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6824
Mailing Address - Country:US
Mailing Address - Phone:405-310-3561
Mailing Address - Fax:405-310-4052
Practice Address - Street 1:1225 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6824
Practice Address - Country:US
Practice Address - Phone:405-310-3561
Practice Address - Fax:405-310-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1158103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty