Basic Information
| Provider Information | |||||||||
| NPI: | 1649755158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OKLAHOMA MENTAL HEALTH COUNCIL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RED ROCK BEHAVIORAL HEALTH SERVICES INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1336 N HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748015206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAXWELL-DUVERGER | ||||||||
| AuthorizedOfficialFirstName: | ANGI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER CREDENTIALING AND PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 4054247711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKLAHOMA MENTAL HEALTH COUNCIL | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100635250 | 05 | OK | MEDICAID |