Healthcare Provider Details

I. General information

NPI: 1588700793
Provider Name (Legal Business Name): MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S COMMERCE BLDG A
ARDMORE OK
73401
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5070
  • Fax: 580-223-5617
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-223-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DEBRA WOODBRIDGE
Title or Position: IS COORDINATOR
Credential: CPM
Phone: 580-223-5070