Provider Demographics
NPI:1013062470
Name:ETI - BEYOND THE BELL
Entity Type:Organization
Organization Name:ETI - BEYOND THE BELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-286-3900
Mailing Address - Street 1:245 W WILSHIRE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7754
Mailing Address - Country:US
Mailing Address - Phone:405-286-3900
Mailing Address - Fax:405-286-3911
Practice Address - Street 1:245 W WILSHIRE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7754
Practice Address - Country:US
Practice Address - Phone:405-286-3900
Practice Address - Fax:405-286-3911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200056310A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200056310AMedicaid