Basic Information
| Provider Information | |||||||||
| NPI: | 1114188331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKTREE COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730691307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059196821 | ||||||||
| FaxNumber: | 4053601616 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730691307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059196821 | ||||||||
| FaxNumber: | 4053601616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 11/02/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIVINGSTON III | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEPHENS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4058210897 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 200212700A | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 200212700A | 05 | OK | MEDICAID |