Healthcare Provider Details

I. General information

NPI: 1972880300
Provider Name (Legal Business Name): KREATIVE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 N MAY AVE SUITE 218
OKLAHOMA CITY OK
73112-3909
US

IV. Provider business mailing address

5929 N MAY AVE SUITE 218
OKLAHOMA CITY OK
73112-3909
US

V. Phone/Fax

Practice location:
  • Phone: 405-254-5040
  • Fax: 405-254-5760
Mailing address:
  • Phone: 405-254-5040
  • Fax: 405-254-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOK

VIII. Authorized Official

Name: MRS. KEITHA DONELLE WYATT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 405-254-5040