Provider Demographics
NPI:1790963445
Name:WESLEYAN YOUTH INC.
Entity Type:Organization
Organization Name:WESLEYAN YOUTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-524-4457
Mailing Address - Street 1:4500 N CLASSEN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4834
Mailing Address - Country:US
Mailing Address - Phone:405-524-4457
Mailing Address - Fax:405-524-5762
Practice Address - Street 1:605 SW B AVE
Practice Address - Street 2:#3
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3962
Practice Address - Country:US
Practice Address - Phone:405-524-4457
Practice Address - Fax:405-524-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK8600030322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1008033130DMedicaid