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General NPI Number Information
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NPI Number | 1265083380
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Entity Type | Organization
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Legal Business Name | MODOC TRIBE OF OKLAHOMA
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 02/20/2025
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Provider Practice Location Address
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Address Line | 10025 SOUTH 705 ROAD
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City | WYANDOTTE
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State | OK
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Zip | 74370
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Country | US
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Telephone | 918-303-5433
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Fax |
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Provider Business Mailing Address
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Address Line | 22 N EIGHT TRIBES TRL
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City | MIAMI
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State | OK
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Zip | 74354-1011
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Country | US
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Telephone | 918-542-1190
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JESSICA MULLIN
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Credential | LCSW
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Telephone | 918-533-7903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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