Basic Information
| Provider Information | |||||||||
| NPI: | 1912291543 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH ASSOCIATION IN TULSA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3322 E 30TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741146108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183822412 | ||||||||
| FaxNumber: | 9185851263 | ||||||||
| Practice Location | |||||||||
| Address1: | 3322 E 30TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741146108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183822412 | ||||||||
| FaxNumber: | 9185851263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TEAM LEADER | ||||||||
| AuthorizedOfficialTelephone: | 9189556245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OK | Y | Agencies | Case Management |
No ID Information.