Basic Information
| Provider Information | |||||||||
| NPI: | 1841564358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 103 GIBBS | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73072 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 GIBBS | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053605100 | ||||||||
| FaxNumber: | 4055733966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2012 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OTOTIVO | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | ZACHARY | ||||||||
| AuthorizedOfficialTitleorPosition: | TRIAGE SPECIALIST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4053605100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.