Healthcare Provider Details

I. General information

NPI: 1750456588
Provider Name (Legal Business Name): STATE OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 10TH STREET, SUITE 211 NORTHWEST CENTER FOR BEHAVIORAL HEALTH
WOODWARD OK
73801-3156
US

IV. Provider business mailing address

1222 10TH STREET, SUITE 211 NORTHWEST CENTER FOR BEHAVIORAL HEALTH
WOODWARD OK
73801-3156
US

V. Phone/Fax

Practice location:
  • Phone: 580-571-3217
  • Fax: 580-256-8609
Mailing address:
  • Phone: 580-571-3217
  • Fax: 580-256-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AUTUMN NICKELSON
Title or Position: EXECUTIVE DIRECTOR
Credential: LADC/LCSW
Phone: 580-571-3231