Healthcare Provider Details

I. General information

NPI: 1386665743
Provider Name (Legal Business Name): PRODIGY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 S MUSKOGEE AVE
TAHLEQUAH OK
74464-4734
US

IV. Provider business mailing address

PO BOX 1247
TAHLEQUAH OK
74465-1247
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-8399
  • Fax: 918-456-8773
Mailing address:
  • Phone: 918-456-8399
  • Fax: 918-456-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SUSAN HOPE ROBERTS
Title or Position: DIRECTOR
Credential: LPC
Phone: 918-456-8399