=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760262364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OKLAHOMA DISABILITY SERVICE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2023
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 WALL ST STE 200
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-615-9721
-----------------------------------------------------
Fax | 405-579-7563
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 WALL ST STE 200
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-615-9721
-----------------------------------------------------
Fax | 405-579-7563
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT MARTIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 405-615-9721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------