Provider Demographics
NPI:1295091411
Name:BRIAN A. BOATWRIGHT, PSY.D., P.L.L.C.
Entity type:Organization
Organization Name:BRIAN A. BOATWRIGHT, PSY.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOATWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:615-415-5767
Mailing Address - Street 1:2935 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5642
Mailing Address - Country:US
Mailing Address - Phone:615-415-5767
Mailing Address - Fax:
Practice Address - Street 1:5272 S LEWIS AVE STE 250
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6564
Practice Address - Country:US
Practice Address - Phone:918-524-3300
Practice Address - Fax:918-524-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1144103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty