Basic Information
| Provider Information | |||||||||
| NPI: | 1821120189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH OKLAHOMA COUNTY MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12978 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058582700 | ||||||||
| FaxNumber: | 4058582810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2617 GENERAL PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731076437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058581700 | ||||||||
| FaxNumber: | 4058582810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLIFTON | ||||||||
| AuthorizedOfficialFirstName: | DEENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP RCM | ||||||||
| AuthorizedOfficialTelephone: | 4058582700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CMPE | ||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100735340F | 05 | OK | MEDICAID | 10073534OK | 05 | OK | MEDICAID | 100735340C | 05 | OK | MEDICAID |