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NPI Code Detail

MEDICARE: STATE OF OKLAHOMA

MEDICARE: STATE OF OKLAHOMA
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
1251S00000XCommunity/Behavioral Health Agency
2261QM2500XMedical Specialty Clinic/Center

Other Identifiers

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

General Provider Information

NPI Number : 1750456588
Entity Type Code : Organization
Provider Name (Legal Business Name) : STATE OF OKLAHOMA
Provider Business Mailing Address
First Line : 1222 10TH STREET, SUITE 211
Second Line : NORTHWEST CENTER FOR BEHAVIORAL HEALTH
City : WOODWARD
State : OK
Zip : 73801-3156
Country : US
Telephone Number : 580-571-3217
Fax Number : 580-256-8609
Provider Business Practice Location Address
First Line : 1222 10TH STREET, SUITE 211
Second Line : NORTHWEST CENTER FOR BEHAVIORAL HEALTH
City : WOODWARD
State : OK
Zip : 73801-3156
Country : US
Telephone Number : 580-571-3217
Fax Number : 580-256-8609
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : AUTUMN NICKELSON
Credential : LADC/LCSW
Telephone Number : 580-571-3231
Provider Enumeration Date : 11/20/2006
Last Update Date : 03/24/2022

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1497979983 — RICKI RICKARD
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Directions to “STATE OF OKLAHOMA ” Practice Location

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