Provider Demographics
NPI:1528281060
Name:CREOKS MENTAL HEALTH
Entity type:Organization
Organization Name:CREOKS MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-756-9411
Mailing Address - Street 1:P.O. BOX 760
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447
Mailing Address - Country:US
Mailing Address - Phone:918-756-9411
Mailing Address - Fax:918-756-2126
Practice Address - Street 1:209 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859
Practice Address - Country:US
Practice Address - Phone:918-623-2922
Practice Address - Fax:918-756-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100734620G251B00000X
OK100734620D251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734620DMedicaid
OK100734620GMedicaid