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General NPI Number Information
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NPI Number | 1912691908
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Entity Type | Organization
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Legal Business Name | SOUTHWESTERN OKLAHOMA STATE UNIVERSITY
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Dates
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Enumeration Date | 06/05/2023
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Last Update Date | 06/05/2023
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Provider Practice Location Address
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Address Line | 100 CAMPUS DRIVE CENTER FOR HEALTH AND WELL-BEING
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City | WEATHERFORD
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State | OK
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Zip | 73096
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Country | US
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Telephone | 580-774-6039
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Fax | 580-774-7121
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Provider Business Mailing Address
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Address Line | 100 CAMPUS DRIVE CENTER FOR HEALTH AND WELL-BEING
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City | WEATHERFORD
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State | OK
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Zip | 73096
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Country | US
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Telephone | 580-774-6039
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Fax | 580-774-7121
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. SUSAN KAY ELLIS
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Credential | LPC
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Telephone | 580-774-6039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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