Provider Demographics
NPI:1730585340
Name:POORBOY, BETTY JO (PTA)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:JO
Last Name:POORBOY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 E FAIRMONT PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8796
Mailing Address - Country:US
Mailing Address - Phone:918-521-9592
Mailing Address - Fax:
Practice Address - Street 1:3207 E FAIRMONT PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8796
Practice Address - Country:US
Practice Address - Phone:918-521-9592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant