Healthcare Provider Details

I. General information

NPI: 1114058070
Provider Name (Legal Business Name): CHARLES B GODDARD HEALTH CENTER COUNSELING AT THE UNIVERSITY OF OK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ELM AVE RM 201
NORMAN OK
73019-3142
US

IV. Provider business mailing address

620 ELM AVE RM 201
NORMAN OK
73019-3142
US

V. Phone/Fax

Practice location:
  • Phone: 405-325-2911
  • Fax: 405-325-1478
Mailing address:
  • Phone: 405-325-2911
  • Fax: 405-325-1478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM WAYNE
Title or Position: DIRECTOR
Credential: PHD
Phone: 405-325-2700