Provider Demographics
NPI:1104089580
Name:ADOLESCENTS AND FAMILIES AT RISK
Entity type:Organization
Organization Name:ADOLESCENTS AND FAMILIES AT RISK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXCECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-402-9858
Mailing Address - Street 1:9421 E 95TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6166
Mailing Address - Country:US
Mailing Address - Phone:918-402-9858
Mailing Address - Fax:
Practice Address - Street 1:9421 E 95TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6166
Practice Address - Country:US
Practice Address - Phone:918-402-9858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1581261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)