Healthcare Provider Details

I. General information

NPI: 1003949439
Provider Name (Legal Business Name): COMMUNITY YOUTH SERVICES OF SOUTHERN OKLAHOMA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PARK ST SE
ARDMORE OK
73401-8364
US

IV. Provider business mailing address

830 PARK ST SE
ARDMORE OK
73401-8364
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-1838
  • Fax: 580-223-7856
Mailing address:
  • Phone: 580-226-1838
  • Fax: 580-223-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAYLYN DAWN WELDON GARY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 580-226-1838