Provider Demographics
NPI:1063693521
Name:NEELY, ROBERTA I (RPT)
Entity type:Individual
Prefix:MISS
First Name:ROBERTA
Middle Name:I
Last Name:NEELY
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 GEORGE NIGH EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:918-423-8440
Mailing Address - Fax:918-423-6889
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571
Practice Address - Country:US
Practice Address - Phone:918-423-8440
Practice Address - Fax:918-423-6889
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2198225100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist