Provider Demographics
NPI:1215293220
Name:DEDICATED OUTPATIENT THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:DEDICATED OUTPATIENT THERAPY SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASHORUN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:405-650-7278
Mailing Address - Street 1:920770 DEER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-8146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920770 DEER RIDGE LN
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881-8146
Practice Address - Country:US
Practice Address - Phone:405-650-7278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100724728BMedicaid