Provider Demographics
NPI:1295154581
Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Entity type:Organization
Organization Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-924-6363
Mailing Address - Street 1:630 N CRAYCROFT RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1440
Mailing Address - Country:US
Mailing Address - Phone:520-747-6600
Mailing Address - Fax:520-747-6613
Practice Address - Street 1:116 SE AVE N
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-5234
Practice Address - Country:US
Practice Address - Phone:580-924-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health