Provider Demographics
NPI:1760481899
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:JIM TALIAFERRO COMMUNITY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-250-2640
Mailing Address - Street 1:602 SW 38TH STREET
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6912
Mailing Address - Country:US
Mailing Address - Phone:580-248-5780
Mailing Address - Fax:580-353-3202
Practice Address - Street 1:602 SW 38TH STREET
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:580-353-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00051112084P0800X, 283Q00000X
283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283Q00000XHospitalsPsychiatric HospitalGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100688870AMedicaid
OK100700660AMedicaid
OK100677270AMedicaid
OK1007558860AMedicaid
OK100706940LMedicaid
OK100706940LMedicaid
OK1007558860AMedicaid