Healthcare Provider Details

I. General information

NPI: 1568753101
Provider Name (Legal Business Name): CATOOSA HOPE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N HIGHWAY 66 STE F
CATOOSA OK
74015-2409
US

IV. Provider business mailing address

1755 N HIGHWAY 66 STE F
CATOOSA OK
74015-2409
US

V. Phone/Fax

Practice location:
  • Phone: 918-739-4885
  • Fax: 918-739-4885
Mailing address:
  • Phone: 918-739-4885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: DR. KYLA LUSSIER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 918-739-4885