Provider Demographics
NPI:1194440073
Name:OKLAHOMA KIDS PSYCHOLOGICAL SERVICE CENTER
Entity type:Organization
Organization Name:OKLAHOMA KIDS PSYCHOLOGICAL SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRACLE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:209-261-4008
Mailing Address - Street 1:128 W I 240 SERVICE RD # 1141
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8031
Mailing Address - Country:US
Mailing Address - Phone:405-339-2245
Mailing Address - Fax:
Practice Address - Street 1:937 SW 89TH ST STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9231
Practice Address - Country:US
Practice Address - Phone:405-339-2245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200587910AMedicaid