Provider Demographics
NPI:1588723548
Name:FAMILY DEVELOPMENT AND INTERVENTION SERVICES
Entity type:Organization
Organization Name:FAMILY DEVELOPMENT AND INTERVENTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:CORNELL
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:405-767-1126
Mailing Address - Street 1:5131 N CLASSEN BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5258
Mailing Address - Country:US
Mailing Address - Phone:405-767-1126
Mailing Address - Fax:405-767-6285
Practice Address - Street 1:5131 N CLASSEN BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5258
Practice Address - Country:US
Practice Address - Phone:405-767-1126
Practice Address - Fax:405-767-6285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200094410AMedicaid