1629341342 NPI number — CREOKS MENTAL HEALTH SEERVICES

Table of content: (NPI 1629341342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629341342 NPI number — CREOKS MENTAL HEALTH SEERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREOKS MENTAL HEALTH SEERVICES
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:
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:
1629341342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 SOUTH YALE AVE, STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-382-7300
Provider Business Mailing Address Fax Number:
918-382-7302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S DEWEY AVE STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTLESVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74003-3525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-336-0810
Provider Business Practice Location Address Fax Number:
918-336-0836
Provider Enumeration Date:
02/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
918-382-7300

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  CMHC-561 , 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: 100734620 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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