Provider Demographics
NPI:1922171701
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
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 1:193461 E CT RD 304
Mailing Address - Street 2:
Mailing Address - City:FORT SUPPLY
Mailing Address - State:OK
Mailing Address - Zip Code:73841-0001
Mailing Address - Country:US
Mailing Address - Phone:580-766-2311
Mailing Address - Fax:580-766-2017
Practice Address - Street 1:193461 E CT RD 304
Practice Address - Street 2:
Practice Address - City:FORT SUPPLY
Practice Address - State:OK
Practice Address - Zip Code:73841-0001
Practice Address - Country:US
Practice Address - Phone:580-766-2311
Practice Address - Fax:580-766-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100704080BMedicaid
OK100704080AMedicaid