Provider Demographics
NPI:1285779314
Name:JIM TALIAFERRO CMHC
Entity type:Organization
Organization Name:JIM TALIAFERRO CMHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTOTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:LBP, LADC
Authorized Official - Phone:580-248-5780
Mailing Address - Street 1:110 SE 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-3416
Mailing Address - Country:US
Mailing Address - Phone:580-248-5780
Mailing Address - Fax:580-353-3202
Practice Address - Street 1:110 SE 2ND STREET
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-3416
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:580-353-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OK0005111261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100706940DMedicaid
OK100706940IMedicaid
OK100706940DMedicaid
OKCRDBRMedicare UPIN