Basic Information
| Provider Information | |||||||||
| NPI: | 1194440073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA KIDS PSYCHOLOGICAL SERVICE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4330 ADAMS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730691007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057018400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4330 ADAMS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730691007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057018400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2022 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOETZ | ||||||||
| AuthorizedOfficialFirstName: | MIRACLE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2092614008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 200587910A | 05 | OK | MEDICAID |