Healthcare Provider Details

I. General information

NPI: 1639105752
Provider Name (Legal Business Name): SOUTHEASTERN PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MAIN ST
MCALESTER OK
74501-5364
US

IV. Provider business mailing address

PO BOX 1589
MCALESTER OK
74502-1589
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-3700
  • Fax: 918-423-3712
Mailing address:
  • Phone: 918-423-3700
  • Fax: 918-423-3712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1683
License Number StateOK

VIII. Authorized Official

Name: RICHARD T. BOWDEN
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 918-423-3700