Basic Information
Provider Information | |||||||||
NPI: | 1073725610 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY & CHILDREN'S SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | F&CS MENTAL HEALTH CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 650 S PEORIA | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741204429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185879471 | ||||||||
FaxNumber: | 9185601399 | ||||||||
Practice Location | |||||||||
Address1: | 102 N DENVER AVE | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741031806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185821200 | ||||||||
FaxNumber: | 9185601399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 11/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENKINS | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL SERVICES OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9189916650 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC, LMFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 100728760D | 05 | OK |   | MEDICAID |