Provider Demographics
NPI:1245794411
Name:OKLAHOMA PSYCHIATRIC FAMILY CLINIC
Entity Type:Organization
Organization Name:OKLAHOMA PSYCHIATRIC FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HENNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-678-4150
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:OLUSTEE
Mailing Address - State:OK
Mailing Address - Zip Code:73560-0328
Mailing Address - Country:US
Mailing Address - Phone:580-678-4150
Mailing Address - Fax:580-248-1987
Practice Address - Street 1:1390 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5270
Practice Address - Country:US
Practice Address - Phone:580-248-3900
Practice Address - Fax:580-248-1987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty