Basic Information
| Provider Information | |||||||||
| NPI: | 1396818514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF OKLAHOMA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1521 HWY 54 NE | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739421247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803385851 | ||||||||
| FaxNumber: | 5803386022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | TRUDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5805713223 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 100706980B | 05 | OK | MEDICAID |