Healthcare Provider Details

I. General information

NPI: 1033790142
Provider Name (Legal Business Name): OKLAHOMA MENTAL HEALTH COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 11/19/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W. MAIN STREET
EAKLY OK
73033
US

IV. Provider business mailing address

PO BOX 185
EAKLY OK
73033-0185
US

V. Phone/Fax

Practice location:
  • Phone: 405-323-0548
  • Fax:
Mailing address:
  • Phone: 405-323-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN ROBERT DOTY
Title or Position: OWNER
Credential: LPC
Phone: 405-323-0548