Provider Demographics
NPI:1770166779
Name:OK-THERAPLAY
Entity type:Organization
Organization Name:OK-THERAPLAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTNEI
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:580-318-9415
Mailing Address - Street 1:1205 KINGSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3227
Mailing Address - Country:US
Mailing Address - Phone:580-318-9415
Mailing Address - Fax:405-999-4998
Practice Address - Street 1:1205 KINGSTON BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3227
Practice Address - Country:US
Practice Address - Phone:580-318-9415
Practice Address - Fax:405-999-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1609488238Medicaid