Healthcare Provider Details

I. General information

NPI: 1245517929
Provider Name (Legal Business Name): THUNDERBIRD CLUBHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 TRIAD VILLAGE DR
NORMAN OK
73071-2967
US

IV. Provider business mailing address

1251 TRIAD VILLAGE DR
NORMAN OK
73071-2967
US

V. Phone/Fax

Practice location:
  • Phone: 405-321-7331
  • Fax: 405-364-6058
Mailing address:
  • Phone: 405-321-7331
  • Fax: 405-364-6058

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: MS. PAMELA SANFORD
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 405-321-7331