Provider Demographics
NPI:1023695756
Name:OTIS, SYLVIA SHALOM (BCBA)
Entity type:Individual
Prefix:
First Name:SYLVIA
Middle Name:SHALOM
Last Name:OTIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SYLVIA
Other - Middle Name:SHALOM
Other - Last Name:RUEB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7107 S YALE AVE # 161
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7306 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7027
Practice Address - Country:US
Practice Address - Phone:918-280-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-20-45064103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst