1457737025 NPI number — LUSSIER PSYCHIATRIC CLINIC

Table of content: (NPI 1457737025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457737025 NPI number — LUSSIER PSYCHIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUSSIER PSYCHIATRIC CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457737025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5525 E 51ST ST
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135-7461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-200-1742
Provider Business Mailing Address Fax Number:
866-580-7221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5525 E 51ST ST
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-7461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-200-1742
Provider Business Practice Location Address Fax Number:
866-580-7221
Provider Enumeration Date:
08/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHANS
Authorized Official First Name:
CARISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
918-200-1742

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  25858 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200608270 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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