MEDICARE: PSACMA

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

General Provider Information

NPI Number	:	1851618599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSACMA

Provider Business Mailing Address
First Line	:	2611 N MLK AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-3313
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2611 N MLK AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-3313
Country	:	US
Telephone Number	:	405-424-2600
Fax Number	:

Authorized Official
Title or Position	:	ADM ASST
Name	:	WYNONA ANN WILDER
Credential	:
Telephone Number	:	405-520-8336

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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Directions to “PSACMA ” Practice Location

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