Healthcare Provider Details

I. General information

NPI: 1700390671
Provider Name (Legal Business Name): MODERN MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 S REDWOOD AVE
BROKEN ARROW OK
74012-4516
US

IV. Provider business mailing address

609 S REDWOOD AVE
BROKEN ARROW OK
74012-4516
US

V. Phone/Fax

Practice location:
  • Phone: 918-836-0239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KRYSTLE HAHN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 918-815-6567