Basic Information
| Provider Information | |||||||||
| NPI: | 1336203132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN COUNTRY BEHAVIORAL HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186828407 | ||||||||
| FaxNumber: | 9186870976 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186828407 | ||||||||
| FaxNumber: | 9186870976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MIS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9186828407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.