Provider Demographics
NPI:1942322128
Name:EDGE, DONNA SUE (OT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:SUE
Last Name:EDGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:SUE
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1405 4TH AVE NW # 296
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2708
Mailing Address - Country:US
Mailing Address - Phone:580-795-4561
Mailing Address - Fax:580-223-6448
Practice Address - Street 1:1107 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2833
Practice Address - Country:US
Practice Address - Phone:580-226-5566
Practice Address - Fax:580-226-5567
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK707225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200110030AMedicaid