Provider Demographics
NPI:1659613016
Name:TULSA BEHAVIORAL MEDICINE LLC
Entity Type:Organization
Organization Name:TULSA BEHAVIORAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:EXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-938-7701
Mailing Address - Street 1:5272 S LEWIS AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6544
Mailing Address - Country:US
Mailing Address - Phone:918-938-7701
Mailing Address - Fax:918-938-7006
Practice Address - Street 1:5272 S LEWIS AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6544
Practice Address - Country:US
Practice Address - Phone:918-938-7701
Practice Address - Fax:918-938-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10770103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty