Healthcare Provider Details

I. General information

NPI: 1972907178
Provider Name (Legal Business Name): STATE OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MAIN ST
NORMAN OK
73071-5305
US

IV. Provider business mailing address

900 E MAIN ST
NORMAN OK
73071-5305
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-6600
  • Fax: 405-573-3960
Mailing address:
  • Phone: 405-573-6600
  • Fax: 405-573-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY GROSS
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 405-573-6600