Healthcare Provider Details

I. General information

NPI: 1649519109
Provider Name (Legal Business Name): FAMILY AND YOUTH INTERVENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 S LEWIS AVE
TULSA OK
74105-7104
US

IV. Provider business mailing address

2624 N QUINCY AVE
TULSA OK
74106-2604
US

V. Phone/Fax

Practice location:
  • Phone: 918-779-4556
  • Fax: 918-895-6917
Mailing address:
  • Phone: 918-949-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOK

VIII. Authorized Official

Name: MR. MICHAEL BAINES
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 918-852-4695