Basic Information
Provider Information | |||||||||
NPI: | 1407916802 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE SERVICE CORPORATION OF OKLAHOMA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE OF OKLAHOM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 N CRAYCROFT RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857111448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207476600 | ||||||||
FaxNumber: | 5207476613 | ||||||||
Practice Location | |||||||||
Address1: | 134 N 12TH AVE | ||||||||
Address2: |   | ||||||||
City: | DURANT | ||||||||
State: | OK | ||||||||
PostalCode: | 747014718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809246363 | ||||||||
FaxNumber: | 5809240379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOERNING | ||||||||
AuthorizedOfficialFirstName: | BREEANN | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | AR AND BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5207476600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.