Healthcare Provider Details

I. General information

NPI: 1407516370
Provider Name (Legal Business Name): WELLNESS CENTERS OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N WATER AVE
TAHLEQUAH OK
74464-2825
US

IV. Provider business mailing address

217 N WATER AVE
TAHLEQUAH OK
74464-2825
US

V. Phone/Fax

Practice location:
  • Phone: 888-692-6590
  • Fax: 888-692-6590
Mailing address:
  • Phone: 888-692-6590
  • Fax: 888-692-6590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
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: AMANDA EDWARDS
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 888-692-6590