Healthcare Provider Details

I. General information

NPI: 1144073040
Provider Name (Legal Business Name): IDYLL BEHAVIORAL HEALTH SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 SALEM CREEK RD
EDMOND OK
73013-2454
US

IV. Provider business mailing address

15004 SALEM CREEK RD
EDMOND OK
73013-2454
US

V. Phone/Fax

Practice location:
  • Phone: 832-848-7011
  • Fax:
Mailing address:
  • Phone: 682-521-5224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EBELECHUKWU EKWENUGO
Title or Position: APRN
Credential: NP
Phone: 832-848-7011