Healthcare Provider Details

I. General information

NPI: 1790922185
Provider Name (Legal Business Name): STATE OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 SOUTH HARVARD
TULSA OK
74114
US

IV. Provider business mailing address

2323 SOUTH HARVARD
TULSA OK
74114
US

V. Phone/Fax

Practice location:
  • Phone: 918-293-2140
  • Fax: 918-912-7164
Mailing address:
  • Phone: 918-293-2140
  • Fax: 918-912-7164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILFRED STEPHEN SAMPSON
Title or Position: CLINICAL BEHAVIORAL HEALTHCARE SPEC
Credential: MS
Phone: 918-293-2140