Provider Demographics
NPI:1093349003
Name:MENTAL HEALTH SERVICE OF SOUTHERN OKLAHOMA
Entity Type:Organization
Organization Name:MENTAL HEALTH SERVICE OF SOUTHERN OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-319-7305
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-319-7305
Mailing Address - Fax:580-319-7328
Practice Address - Street 1:2425 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2942
Practice Address - Country:US
Practice Address - Phone:580-924-7330
Practice Address - Fax:580-924-2739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830Medicaid