Healthcare Provider Details

I. General information

NPI: 1619208147
Provider Name (Legal Business Name): SPUR OUTPATIENT SERVICES DBA SOUTHWEST FOSTER CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N CLASSEN BLVD STE 135
OKLAHOMA CITY OK
73118-4624
US

IV. Provider business mailing address

4801 N. CLASSEN BLVD SUITE 135
OKLAHOMA CITY OK
73118-4624
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-0011
  • Fax: 405-848-2111
Mailing address:
  • Phone: 405-848-0011
  • Fax: 405-848-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1465
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1465
License Number StateOK

VIII. Authorized Official

Name: MS. STEPHANIE ANN BRILL
Title or Position: LEAD CLINICIAN
Credential: LCSW
Phone: 405-848-0011