Basic Information
Provider Information | |||||||||
NPI: | 1720152788 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF OKLAHOMA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1222 10TH STREET, SUITE 211 | ||||||||
Address2: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
City: | WOODWARD | ||||||||
State: | OK | ||||||||
PostalCode: | 738013156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5805713217 | ||||||||
FaxNumber: | 5802568609 | ||||||||
Practice Location | |||||||||
Address1: | 702 N. GRAND | ||||||||
Address2: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 73701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802343791 | ||||||||
FaxNumber: | 5802377711 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 02/27/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOFFMAN | ||||||||
AuthorizedOfficialFirstName: | TRUDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5805713233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 100646280D | 05 | OK |   | MEDICAID |