MEDICARE: CAMELOT COMMUNITY SERVICES OF OKLAHOMA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417011081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELOT COMMUNITY SERVICES OF OKLAHOMA, LLC

Provider Business Mailing Address
First Line	:	4207 E HIGHWAY 290
Second Line	:
City	:	DRIPPING SPRINGS
State	:	TX
Zip	:	78620-4206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2816 E JACKSON ST
Second Line	:	SUITE C
City	:	HUGO
State	:	OK
Zip	:	74743-4250
Country	:	US
Telephone Number	:	580-326-5350
Fax Number	:

Authorized Official
Title or Position	:	EXEC DIR
Name	:	DERREL LEVY
Credential	:	LPC
Telephone Number	:	580-298-2830

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	11/18/2009

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