Healthcare Provider Details

I. General information

NPI: 1629087895
Provider Name (Legal Business Name): YCO TULSA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 JANETS WAY STE B
ELK CITY OK
73644-4803
US

IV. Provider business mailing address

PO BOX 95207
OKLAHOMA CITY OK
73143-5207
US

V. Phone/Fax

Practice location:
  • Phone: 580-309-7961
  • Fax:
Mailing address:
  • Phone: 866-926-6552
  • Fax: 580-547-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number100744460E
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LOBATO
Title or Position: CEO
Credential:
Phone: 866-926-6552