Provider Demographics
NPI:1588755532
Name:STATE OF OKLAHOMA
Entity type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:045-573-3953
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-0400
Mailing Address - Country:US
Mailing Address - Phone:405-573-3901
Mailing Address - Fax:405-573-3958
Practice Address - Street 1:909 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5229
Practice Address - Country:US
Practice Address - Phone:405-573-3901
Practice Address - Fax:405-573-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100706950CMedicaid
OK100706950EMedicaid
OK100706950UMedicaid
OK100706950FMedicaid
OK100688910AMedicaid
OK100706950FMedicaid
OKCRDBRMedicare ID - Type UnspecifiedPART B PROVIDER #
OK100679610AMedicaid
OK100706950EMedicaid