MEDICARE: COUNSELING AND MEDIATION SERVICES OF 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1750947487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING AND MEDIATION SERVICES OF OKLAHOMA

Provider Business Mailing Address
First Line	:	909 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-7121
Country	:	US
Telephone Number	:	405-863-5570
Fax Number	:

Provider Business Practice Location Address
First Line	:	13909 TECHNOLOGY DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1056
Country	:	US
Telephone Number	:	405-863-5570
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GARY L HARDWICK
Credential	:
Telephone Number	:	405-863-5570

Provider Enumeration Date	:	05/17/2019
Last Update Date	:	05/17/2019

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