Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 4555 | OK |
NPI | 1447578273 |
---|---|
Provider Name | Courtney Merle Dewbre |
First Address | Ardmore, OK 73401-2540 |
Second Address | Ardmore, OK 73401-2540 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2010 |
Last Update Date | 02/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200425070A | (05) | OK |