Provider Demographics
NPI:1407177306
Name:HARTSELL PSYCHOLOGICAL SERVICES, INC
Entity Type:Organization
Organization Name:HARTSELL PSYCHOLOGICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFFESIONAL COULNSLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KIMBRO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:580-371-9933
Mailing Address - Street 1:504 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMING
Mailing Address - State:OK
Mailing Address - Zip Code:73460
Mailing Address - Country:US
Mailing Address - Phone:580-371-9933
Mailing Address - Fax:580-371-9944
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-9933
Practice Address - Fax:580-371-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3839251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580EMedicaid