Provider Demographics
NPI:1750456588
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:LADC/LCSW
Authorized Official - Phone:580-571-3231
Mailing Address - Street 1:1222 10TH STREET, SUITE 211
Mailing Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-571-3217
Mailing Address - Fax:580-256-8609
Practice Address - Street 1:1222 10TH STREET, SUITE 211
Practice Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3156
Practice Address - Country:US
Practice Address - Phone:580-571-3217
Practice Address - Fax:580-256-8609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707390AMedicaid
OK100707390AMedicaid