Healthcare Provider Details

I. General information

NPI: 1124705348
Provider Name (Legal Business Name): RELIANCE MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 09/02/2025
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 NW 23RD ST
BETHANY OK
73008-5135
US

IV. Provider business mailing address

7415 NW 23RD ST
BETHANY OK
73008-5135
US

V. Phone/Fax

Practice location:
  • Phone: 405-999-9999
  • Fax:
Mailing address:
  • Phone: 405-501-8806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLINE LAMI EDIE
Title or Position: OWNER
Credential: APRN, FNP-C, PMHNP-C
Phone: 405-501-8806