Healthcare Provider Details

I. General information

NPI: 1285779314
Provider Name (Legal Business Name): JIM TALIAFERRO CMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SE 2ND STREET
ANADARKO OK
73005-3416
US

IV. Provider business mailing address

110 SE 2ND STREET
ANADARKO OK
73005-3416
US

V. Phone/Fax

Practice location:
  • Phone: 580-248-5780
  • Fax: 580-353-3202
Mailing address:
  • Phone: 580-248-5780
  • Fax: 580-353-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0005111
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. BRENDA OTOTIVO
Title or Position: EXECUTIVE DIRECTOR
Credential: LBP, LADC
Phone: 580-248-5780