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General NPI Number Information
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NPI Number | 1144653056
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Entity Type | Organization
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Legal Business Name | GROUNDWORK FIRST FAMILY DEVELOPMENT INSTITUTE, LLC
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Dates
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Enumeration Date | 08/14/2013
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 219 N BROADWAY ST
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City | TECUMSEH
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State | OK
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Zip | 74873-3227
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Country | US
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Telephone | 405-326-2256
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Fax |
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Provider Business Mailing Address
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Address Line | 3334 W MAIN ST #293
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City | NORMAN
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State | OK
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Zip | 73072-4805
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Country | US
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Telephone | 405-326-2256
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY D LOOMAN
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Credential | PHD
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Telephone | 405-326-2256
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1727
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License Number State | OK
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