Basic Information
| Provider Information | |||||||||
| NPI: | 1528418795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YUKON PEDIATRICS BEHAVIORAL HEALTH L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 W VANDAMENT AVE | ||||||||
| Address2: | STE. 207 | ||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730994655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052652655 | ||||||||
| FaxNumber: | 4053500024 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 W VANDAMENT AVE | ||||||||
| Address2: | STE. 207 | ||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730994655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052652655 | ||||||||
| FaxNumber: | 4053500024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2016 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | HANES | ||||||||
| AuthorizedOfficialFirstName: | ALECIA | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4052652655 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.