Basic Information
| Provider Information | |||||||||
| NPI: | 1295154581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE SERVICE CORPORATION OF OKLAHOMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 N CRAYCROFT RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857111440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207476600 | ||||||||
| FaxNumber: | 5207476613 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 SE AVE N | ||||||||
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| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747455234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809246363 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | RICHEY | ||||||||
| AuthorizedOfficialFirstName: | LYNNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | STATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5809246363 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.