Provider Demographics
NPI:1063607117
Name:KICKAPOO BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:KICKAPOO BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLA
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:405-964-2081
Mailing Address - Street 1:407 NORTH HIGHWAY 102
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851
Mailing Address - Country:US
Mailing Address - Phone:405-964-2081
Mailing Address - Fax:405-964-5677
Practice Address - Street 1:404 NORTH HIGHWAY 102
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851
Practice Address - Country:US
Practice Address - Phone:405-964-2081
Practice Address - Fax:405-964-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK98261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicaid