Basic Information
| Provider Information | |||||||||
| NPI: | 1104196385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BHRS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 805 W PELTON ST | ||||||||
| Address2: | |||||||||
| City: | SHERMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750922947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032724611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | 5809318022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2012 | ||||||||
| LastUpdateDate: | 01/05/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 200049040 | 05 | OK | MEDICAID |