Healthcare Provider Details

I. General information

NPI: 1427722370
Provider Name (Legal Business Name): LIFE PSYCHIATRIC CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 S KELLY AVE STE B2
EDMOND OK
73003-5725
US

IV. Provider business mailing address

609 S KELLY AVE STE B2
EDMOND OK
73003-5725
US

V. Phone/Fax

Practice location:
  • Phone: 405-724-6871
  • Fax: 405-726-0423
Mailing address:
  • Phone: 405-724-6871
  • Fax: 405-726-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MEBIN BABU THOMAS
Title or Position: MEMBER
Credential: PA-C
Phone: 405-414-9139