Provider Demographics
NPI:1699838565
Name:CAMELOT COMMUNITY SERVICES OF OKLAHOMA, LLC
Entity Type:Organization
Organization Name:CAMELOT COMMUNITY SERVICES OF OKLAHOMA, LLC
Other - Org Name:COUNSELING CENTER OF SE OKLAHOMA
Other - Org Type:Other Name
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:
Authorized Official - First Name:DERREL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-298-2830
Mailing Address - Street 1:4207 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3934
Practice Address - Country:US
Practice Address - Phone:580-584-6054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744370DMedicaid