Provider Demographics
NPI:1871575399
Name:ISENBERG, ROY M (PHD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:M
Last Name:ISENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-6030
Mailing Address - Country:US
Mailing Address - Phone:404-415-2303
Mailing Address - Fax:415-415-2301
Practice Address - Street 1:717 NW 56TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-6030
Practice Address - Country:US
Practice Address - Phone:404-415-2303
Practice Address - Fax:415-415-2301
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK313103TC1900X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
R11022Medicare UPIN