Healthcare Provider Details

I. General information

NPI: 1467617928
Provider Name (Legal Business Name): MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 BROADLAWN VILLAGE
ARDMORE OK
73401-1722
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-2537
  • Fax: 580-223-2487
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-223-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E. LEE
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 580-223-5070