MEDICARE: FAMILY DEVELOPMENT AND INTERVENTION SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	261QM0801X	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588723548
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DEVELOPMENT AND INTERVENTION SERVICES

Provider Business Mailing Address
First Line	:	5131 N CLASSEN BLVD
Second Line	:	SUITE 110
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-5258
Country	:	US
Telephone Number	:	405-767-1126
Fax Number	:	405-767-6285

Provider Business Practice Location Address
First Line	:	5131 N CLASSEN BLVD
Second Line	:	SUITE 110
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-5258
Country	:	US
Telephone Number	:	405-767-1126
Fax Number	:	405-767-6285

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WESLEY CORNELL LONG
Credential	:	PH. D
Telephone Number	:	405-767-1126

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	08/22/2020

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