Provider Demographics
NPI:1912691908
Name:SOUTHWESTERN OKLAHOMA STATE UNIVERSITY
Entity Type:Organization
Organization Name:SOUTHWESTERN OKLAHOMA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-774-6039
Mailing Address - Street 1:100 CAMPUS DRIVE
Mailing Address - Street 2:CENTER FOR HEALTH AND WELL-BEING
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096
Mailing Address - Country:US
Mailing Address - Phone:580-774-6039
Mailing Address - Fax:580-774-7121
Practice Address - Street 1:100 CAMPUS DRIVE
Practice Address - Street 2:CENTER FOR HEALTH AND WELL-BEING
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096
Practice Address - Country:US
Practice Address - Phone:580-774-6039
Practice Address - Fax:580-774-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service