MEDICARE: SERIOUS SOBRIETY AND BEHAVIORAL HEALTH PLLC

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	5484	OK

General Provider Information

NPI Number	:	1952702490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERIOUS SOBRIETY AND BEHAVIORAL HEALTH PLLC

Provider Business Mailing Address
First Line	:	3412 SE 47TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-1308
Country	:	US
Telephone Number	:	405-476-8483
Fax Number	:

Provider Business Practice Location Address
First Line	:	3412 SE 47TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-1308
Country	:	US
Telephone Number	:	405-476-8483
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DERWIN BOLDEN
Credential	:	LPC
Telephone Number	:	405-476-8483

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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