Provider Demographics
NPI:1780867812
Name:MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Entity Type:Organization
Organization Name:MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Other - Org Name:MENTAL HEALTH AND SUBSTANCE ABUSE CENTERS OF SOUTHERN OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:580-223-5070
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-223-5070
Mailing Address - Fax:580-223-5617
Practice Address - Street 1:209 E WILSON ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2200
Practice Address - Country:US
Practice Address - Phone:580-371-0109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830FMedicaid
OKMHSSWMedicare PIN