=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134291578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 N 6TH ST
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-762-7561
-----------------------------------------------------
Fax | 580-762-2576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 N 6TH ST
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-762-7561
-----------------------------------------------------
Fax | 580-762-2576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. GEOFFREY HOMER COWAN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 580-762-7561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------