Provider Demographics
NPI:1427257013
Name:IMAGINE PEDIATRIC THERAPY, PLLC
Entity type:Organization
Organization Name:IMAGINE PEDIATRIC THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANG
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:918-269-4128
Mailing Address - Street 1:9930 E 510 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-5103
Mailing Address - Country:US
Mailing Address - Phone:918-269-4128
Mailing Address - Fax:918-343-7491
Practice Address - Street 1:12899 E 76TH ST N UNIT NO117
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4026
Practice Address - Country:US
Practice Address - Phone:918-609-6003
Practice Address - Fax:918-609-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK944225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS
OK=========OtherTRICARE