Provider Demographics
NPI:1700950201
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LADC/LCSW
Authorized Official - Phone:580-571-3231
Mailing Address - Street 1:1222 10TH STREET, SUITE 211
Mailing Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-571-3217
Mailing Address - Fax:580-256-8609
Practice Address - Street 1:5050 WILLIAMS AVENUE
Practice Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-256-9700
Practice Address - Fax:580-256-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility