Provider Demographics
NPI:1295077659
Name:OLIVER, ALPHONZO R SR (MHR, BHRS)
Entity type:Individual
Prefix:
First Name:ALPHONZO
Middle Name:R
Last Name:OLIVER
Suffix:SR
Gender:M
Credentials:MHR, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9513 MAYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6553
Mailing Address - Country:US
Mailing Address - Phone:405-414-1367
Mailing Address - Fax:
Practice Address - Street 1:9513 MAYBROOK DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6553
Practice Address - Country:US
Practice Address - Phone:405-414-1367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKASCX12Medicaid