Provider Demographics
NPI:1194077073
Name:OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE
Entity type:Organization
Organization Name:OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:405-522-6853
Mailing Address - Street 1:1200 NE 13TH ST
Mailing Address - Street 2:P.O. BOX 53277
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1022
Mailing Address - Country:US
Mailing Address - Phone:405-522-6853
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1022
Practice Address - Country:US
Practice Address - Phone:405-522-6853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2747251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health