Provider Demographics
NPI:1336335314
Name:SOUTHERN OKLAHOMA PSYCHOLOGICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA PSYCHOLOGICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIGDOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-332-9531
Mailing Address - Street 1:422 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6949
Mailing Address - Country:US
Mailing Address - Phone:580-332-9531
Mailing Address - Fax:
Practice Address - Street 1:422 S HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6949
Practice Address - Country:US
Practice Address - Phone:580-332-9531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty