Healthcare Provider Details

I. General information

NPI: 1558686246
Provider Name (Legal Business Name): LATINO COMMUNITY DEVELOPMENT AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 SW 10TH ST
OKLAHOMA CITY OK
73109-5610
US

IV. Provider business mailing address

420 SW 10TH ST
OKLAHOMA CITY OK
73109-5610
US

V. Phone/Fax

Practice location:
  • Phone: 405-236-0701
  • Fax: 405-236-0773
Mailing address:
  • Phone: 405-236-0701
  • Fax: 405-236-0773

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: PATRICIA B. FENNELL
Title or Position: PRESIDENT/CEO
Credential: MSW
Phone: 405-236-0701