Healthcare Provider Details

I. General information

NPI: 1508987959
Provider Name (Legal Business Name): STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S. HENSLEY DR
TAHLEQUAH OK
74465-0558
US

IV. Provider business mailing address

1400 S. HENSLEY DR P.O. BOX 558
TAHLEQUAH OK
74465-0558
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-3049
  • Fax: 918-207-3065
Mailing address:
  • Phone: 918-207-3049
  • Fax: 918-207-3065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number36-4537
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier29393
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerSTATE BNDD CONTROL NUMBER
# 2
Identifier364537
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerSTATE BOARD OF PHARMACY L

VIII. Authorized Official

Name: MR. WALTER MICHAEL KINNEY
Title or Position: DIRECTOR OF PHARMACY
Credential: DPH
Phone: 918-207-3049