Basic Information
| Provider Information | |||||||||
| NPI: | 1285707406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF OKLAHOMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
| Address2: | 1222 10TH STREET, SUITE 211 | ||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738013156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805713217 | ||||||||
| FaxNumber: | 5802568609 | ||||||||
| Practice Location | |||||||||
| Address1: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
| Address2: | 124 E. SHERIDAN | ||||||||
| City: | KINGFISHER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053756377 | ||||||||
| FaxNumber: | 4053756377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | TRUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5805713233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100646280B | 05 | OK | MEDICAID |