Provider Demographics
NPI:1265697726
Name:MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Entity type:Organization
Organization Name:MENTAL HEALTH SERVICES OF SOUTHERN OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:580-223-5070
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-223-5070
Mailing Address - Fax:580-223-5617
Practice Address - Street 1:93 BROADLAWN VILLAGE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1722
Practice Address - Country:US
Practice Address - Phone:580-223-2537
Practice Address - Fax:580-223-2487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830Medicaid