Provider Demographics
NPI:1578580916
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:TULSA CENTER FOR BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-256-8615
Mailing Address - Street 1:2323 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3301
Mailing Address - Country:US
Mailing Address - Phone:918-293-2140
Mailing Address - Fax:918-293-2195
Practice Address - Street 1:2323 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3301
Practice Address - Country:US
Practice Address - Phone:918-293-2140
Practice Address - Fax:918-712-7164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707460Medicaid