MEDICARE: MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA

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	251S00000X	Community/Behavioral Health Agency

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	:	1487076550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA

Provider Business Mailing Address
First Line	:	9432 N MAY AVE
Second Line	:	SUITE D-2
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-2716
Country	:	US
Telephone Number	:	405-608-8030
Fax Number	:

Provider Business Practice Location Address
First Line	:	9432 N MAY AVE
Second Line	:	SUITE D-2
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-2716
Country	:	US
Telephone Number	:	405-608-8030
Fax Number	:

Authorized Official
Title or Position	:	DEPUTY EXECUTIVE DIRECTOR
Name	:	DEANA THARP
Credential	:	LPC
Telephone Number	:	580-223-5070

Provider Enumeration Date	:	01/09/2014
Last Update Date	:	01/09/2014

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