MEDICARE: MODOC NATION BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821636358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODOC NATION BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	22 N EIGHT TRIBES TRL
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-1011
Country	:	US
Telephone Number	:	918-387-8720
Fax Number	:	918-238-4225

Provider Business Practice Location Address
First Line	:	24 N EIGHT TRIBES TRL
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-1011
Country	:	US
Telephone Number	:	918-387-8720
Fax Number	:	918-956-2970

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	LACI BARTON
Credential	:	APRN-CNP
Telephone Number	:	918-387-8720

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	04/14/2026

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