Provider Demographics
NPI:1699506725
Name:BRAINSTORM PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:BRAINSTORM PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:918-808-9084
Mailing Address - Street 1:3871 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5056
Mailing Address - Country:US
Mailing Address - Phone:918-808-9084
Mailing Address - Fax:
Practice Address - Street 1:215 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3658
Practice Address - Country:US
Practice Address - Phone:918-216-0162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty