Healthcare Provider Details

I. General information

NPI: 1336203132
Provider Name (Legal Business Name): GREEN COUNTRY BEHAVIORAL HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N MAIN ST
MUSKOGEE OK
74401-4431
US

IV. Provider business mailing address

619 N MAIN ST
MUSKOGEE OK
74401-4431
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-8407
  • Fax: 918-687-0976
Mailing address:
  • Phone: 918-682-8407
  • Fax: 918-687-0976

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 StateOK

VIII. Authorized Official

Name: MARK BRIAN JOHNSON
Title or Position: MIS DIRECTOR
Credential:
Phone: 918-682-8407