Provider Demographics
NPI:1376587139
Name:TULSA FAMILY DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:TULSA FAMILY DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOODHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:CMA (AAMA)
Authorized Official - Phone:918-299-8232
Mailing Address - Street 1:4520 S HARVARD AVE STE 200C
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2925
Mailing Address - Country:US
Mailing Address - Phone:918-743-3224
Mailing Address - Fax:918-743-9623
Practice Address - Street 1:4520 S HARVARD AVE STE 200C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2925
Practice Address - Country:US
Practice Address - Phone:918-743-3224
Practice Address - Fax:918-743-9623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC0700X, 103TC1900X, 2084P0804X
OK878103TC0700X
AR06-09P103TC0700X
OK191262080P0006X
OK127192080P0006X
OK177112080P0006X
OK611103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1320OtherPSYCHOLOGIST LICENSE
OK411OtherPSYCHOLOGIST LICENSE
OK12719OtherMEDICAL LICENSE
OK878OtherPSYCHOLOGIST LICENSE
OK17711OtherMEDICAL LICENSE
OK19126OtherMEDICAL LICENSE
OK411OtherPSYCHOLOGIST LICENSE
OK611OtherPSYCHOLOGIST LICENSE
OK440OtherPSYCHOLOGIST LICENSE
AR06-09POtherPSYCHOLOGIST LICENSE
OK611OtherPSYCHOLOGIST LICENSE