Provider Demographics
NPI:1770963480
Name:OSBORNE, BODEREK
Entity type:Individual
Prefix:
First Name:BODEREK
Middle Name:
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8311 NE 34TH PL
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-3111
Mailing Address - Country:US
Mailing Address - Phone:405-816-4450
Mailing Address - Fax:
Practice Address - Street 1:8311 NE 34TH PL
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-3111
Practice Address - Country:US
Practice Address - Phone:405-816-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst