Provider Demographics
NPI:1508987959
Name:STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-207-3049
Mailing Address - Street 1:1400 S. HENSLEY DR
Mailing Address - Street 2:P.O. BOX 558
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0558
Mailing Address - Country:US
Mailing Address - Phone:918-207-3049
Mailing Address - Fax:918-207-3065
Practice Address - Street 1:1400 S. HENSLEY DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74465-0558
Practice Address - Country:US
Practice Address - Phone:918-207-3049
Practice Address - Fax:918-207-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK36-4537261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK29393OtherSTATE BNDD CONTROL NUMBER
OK364537OtherSTATE BOARD OF PHARMACY L
OK364537OtherSTATE BOARD OF PHARMACY L