Provider Demographics
NPI:1265083380
Name:MODOC TRIBE OF OKLAHOMA
Entity type:Organization
Organization Name:MODOC TRIBE OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:918-533-7903
Mailing Address - Street 1:22 N EIGHT TRIBES TRL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-1011
Mailing Address - Country:US
Mailing Address - Phone:918-542-1190
Mailing Address - Fax:
Practice Address - Street 1:10025 SOUTH 705 ROAD
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:OK
Practice Address - Zip Code:74370
Practice Address - Country:US
Practice Address - Phone:918-303-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty