Organization
STATE OF OKLAHOMA
Active
Other names
Northwest Center for Behavioral Health
Organization subpart
No
Provider details
NPI number
Authorized official
AUTUMN NICKELSON LADC/LCSW (EXECUTIVE DIRECTOR)
(580) 571-3231
Entity
Organization
Contact information
Practice address
193461 E CT RD 304, FORT SUPPLY, OK 73841-0001
(580) 766-2311
(580) 766-2017
Mailing address
193461 E CT RD 304, FORT SUPPLY, OK 73841-0001
(580) 766-2311
(580) 766-2017
Taxonomy
Speciality
Code
Description
License number
State
283Q00000X
Psychiatric Hospital
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100704080A
—
OK
05
—
100704080B
—
OK
Enumeration date
11/17/2006
Last updated
12/11/2023
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