Basic Information
| Provider Information | |||||||||
| NPI: | 1033364435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALIZED ALTERNATIVES FOR FAMILIES AND YOUTH OF OKLAHOMA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SAFY OF ALTUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10100 ELIDA RD | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196958010 | ||||||||
| FaxNumber: | 4196950004 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N LEE ST | ||||||||
| Address2: | |||||||||
| City: | ALTUS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735213818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803558883 | ||||||||
| FaxNumber: | 5803558885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HULL | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8177892611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW, LCPA, LCCA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 100710730G | 05 | OK | MEDICAID |