Provider Demographics
NPI:1245517929
Name:THUNDERBIRD CLUBHOUSE
Entity type:Organization
Organization Name:THUNDERBIRD CLUBHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-321-7331
Mailing Address - Street 1:1251 TRIAD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2967
Mailing Address - Country:US
Mailing Address - Phone:405-321-7331
Mailing Address - Fax:405-364-6058
Practice Address - Street 1:1251 TRIAD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-2967
Practice Address - Country:US
Practice Address - Phone:405-321-7331
Practice Address - Fax:405-364-6058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200268830AMedicaid