Healthcare Provider Details

I. General information

NPI: 1942334768
Provider Name (Legal Business Name): WAYNOKA MENTAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 NICKERSON ST
WAYNOKA OK
73860-1252
US

IV. Provider business mailing address

PO BOX 135
WAYNOKA OK
73860-0135
US

V. Phone/Fax

Practice location:
  • Phone: 580-824-0674
  • Fax: 580-824-0676
Mailing address:
  • Phone: 580-824-0674
  • Fax: 580-824-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number76244
License Number StateOK

VIII. Authorized Official

Name: MR. SIDNEY DON SMILEY
Title or Position: CHAIRMAN OF THE TRUSTEE BOARD
Credential: MED IN COUNSELING
Phone: 580-824-0674