Provider Demographics
NPI:1376311209
Name:PHOBOS BEHAVIORAL OF SOUTH TULSA LLC
Entity Type:Organization
Organization Name:PHOBOS BEHAVIORAL OF SOUTH TULSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, NCSP, LBP
Authorized Official - Phone:539-240-4735
Mailing Address - Street 1:8242 S HARVARD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1648
Mailing Address - Country:US
Mailing Address - Phone:918-392-3461
Mailing Address - Fax:918-550-8228
Practice Address - Street 1:8242 S HARVARD AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1648
Practice Address - Country:US
Practice Address - Phone:918-392-3461
Practice Address - Fax:918-550-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty