Provider Demographics
NPI:1972648004
Name:JIM TALIAFERRO CMHC
Entity Type:Organization
Organization Name:JIM TALIAFERRO CMHC
Other - Org Name:
Other - Org Type:
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 1:411 FOWLER DR
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-2336
Mailing Address - Country:US
Mailing Address - Phone:580-248-5780
Mailing Address - Fax:580-353-3202
Practice Address - Street 1:411 FOWLER DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-2336
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:2007-02-20
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OK0005111261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100706940CMedicaid
OK100706940JMedicaid
OK100706940JMedicaid
OKCRDBRMedicare UPIN