Healthcare Provider Details

I. General information

NPI: 1376311209
Provider Name (Legal Business Name): PHOBOS BEHAVIORAL OF SOUTH TULSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8242 S HARVARD AVE STE A
TULSA OK
74137-1648
US

IV. Provider business mailing address

8242 S HARVARD AVE STE A
TULSA OK
74137-1648
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-3461
  • Fax: 918-550-8228
Mailing address:
  • Phone: 918-392-3461
  • Fax: 918-550-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY TYLER OWENS
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA, NCSP, LBP
Phone: 539-240-4735