Provider Demographics
NPI:1346547908
Name:JIM TALIAFERRO COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:JIM TALIAFERRO COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FETIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-355-0072
Mailing Address - Street 1:602 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6912
Mailing Address - Country:US
Mailing Address - Phone:580-355-0072
Mailing Address - Fax:580-355-0232
Practice Address - Street 1:602 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-355-0072
Practice Address - Fax:580-355-0232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2612MQM0801X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health