Provider Demographics
NPI:1457737025
Name:LUSSIER PSYCHIATRIC CLINIC
Entity Type:Organization
Organization Name:LUSSIER PSYCHIATRIC CLINIC
Other - Org Name:LUSSIER PSYCHIATRIC CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-200-1742
Mailing Address - Street 1:5525 E 51ST ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7461
Mailing Address - Country:US
Mailing Address - Phone:918-200-1742
Mailing Address - Fax:866-580-7221
Practice Address - Street 1:5525 E 51ST ST
Practice Address - Street 2:SUITE 310
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7461
Practice Address - Country:US
Practice Address - Phone:918-200-1742
Practice Address - Fax:866-580-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK258582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200608270 AMedicaid
OK448955Medicare PIN