Basic Information
Provider Information
NPI: 1003138710
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOSLEY
FirstName: TREBOR
MiddleName: WELLINGTON
NamePrefix:  
NameSuffix:  
Credential: M.H.R.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4421 APPLE BLOSSOM CIR
Address2:  
City: MOORE
State: OK
PostalCode: 731601007
CountryCode: US
TelephoneNumber: 4055351048
FaxNumber:  
Practice Location
Address1: 116 W MAIN ST
Address2:  
City: NORMAN
State: OK
PostalCode: 730691307
CountryCode: US
TelephoneNumber: 4059196821
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/22/2010
LastUpdateDate: 02/22/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

ID Information
IDTypeStateIssuerDescription
101YM0800X05OK MEDICAID


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