=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063607117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KICKAPOO BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 NORTH HIGHWAY 102
-----------------------------------------------------
City | MCLOUD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-964-2081
-----------------------------------------------------
Fax | 405-964-5677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 NORTH HIGHWAY 102
-----------------------------------------------------
City | MCLOUD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-964-2081
-----------------------------------------------------
Fax | 405-964-5677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH DIRECTOR
-----------------------------------------------------
Name | MS. WAYNE IRION
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-964-2081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 98
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------