Provider Demographics
NPI:1790922185
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL BEHAVIORAL HEALTHCARE SPEC
Authorized Official - Prefix:MR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:918-293-2140
Mailing Address - Street 1:2323 SOUTH HARVARD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114
Mailing Address - Country:US
Mailing Address - Phone:918-293-2140
Mailing Address - Fax:918-912-7164
Practice Address - Street 1:2323 SOUTH HARVARD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114
Practice Address - Country:US
Practice Address - Phone:918-293-2140
Practice Address - Fax:918-912-7164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Single Specialty