Basic Information
| Provider Information | |||||||||
| NPI: | 1619012515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF OKLAHOMA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JIM TALIAFERRO CMHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 602 SW 38TH STREET | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802485780 | ||||||||
| FaxNumber: | 5803533202 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 SW 38TH STREET | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802485780 | ||||||||
| FaxNumber: | 5803533202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 06/16/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OTOTIVO | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5802485780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF OKLAHOMA DEPARTMENT OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LBP, LADC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 0005111 | OK | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | 0005111 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | WCDLG | 01 | OK | MEDICARE PART B PROVIDER NUMBER | OTHER | 100677270A | 05 | OK | MEDICAID | 100755860A | 05 | OK | MEDICAID | 100688870A | 05 | OK | MEDICAID |