Provider Demographics
NPI:1396818514
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-571-3223
Mailing Address - Street 1:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Mailing Address - Street 2:1222 10TH STREET, SUITE 211
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-571-3217
Mailing Address - Fax:580-256-8609
Practice Address - Street 1:1521 HWY 54 NE
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-1247
Practice Address - Country:US
Practice Address - Phone:580-338-5851
Practice Address - Fax:580-338-6022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100706980BMedicaid
OKWBBGRMedicare ID - Type Unspecified