Basic Information
Provider Information | |||||||||
NPI: | 1174761258 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH OKLAHOMA COUNTY MENTAL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4436 NW 50TH ST | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731122212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058582700 | ||||||||
FaxNumber: | 4058582720 | ||||||||
Practice Location | |||||||||
Address1: | 4436 NW 50TH ST | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731122212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058582700 | ||||||||
FaxNumber: | 4058582720 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2009 | ||||||||
LastUpdateDate: | 01/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ORSI | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4058582754 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 100735340D | 05 | OK |   | MEDICAID |