Healthcare Provider Details

I. General information

NPI: 1801295464
Provider Name (Legal Business Name): MENTAL HEALTH SERVICE OF SOUTHERN OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MAIN ST
DURANT OK
74701-5038
US

IV. Provider business mailing address

1001 W MAIN ST
DURANT OK
74701-5038
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7330
  • Fax: 580-924-2739
Mailing address:
  • Phone: 580-924-7330
  • Fax: 580-924-2739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateOK

VIII. Authorized Official

Name: MR. TROY O'NEAL GLOVER
Title or Position: RECOVERY SUPPORT SPECIALIST
Credential:
Phone: 580-924-7331