Provider Demographics
NPI:1306905096
Name:YOUTH SERVICES OF TULSA
Entity type:Organization
Organization Name:YOUTH SERVICES OF TULSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:9189-582-0061
Mailing Address - Street 1:311 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3208
Mailing Address - Country:US
Mailing Address - Phone:918-582-0061
Mailing Address - Fax:
Practice Address - Street 1:311 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3208
Practice Address - Country:US
Practice Address - Phone:918-582-0061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100710510EMedicaid