Healthcare Provider Details

I. General information

NPI: 1841304250
Provider Name (Legal Business Name): SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 VENTURE DR
NORMAN OK
73069-8215
US

IV. Provider business mailing address

6262 S SHERIDAN RD
TULSA OK
74133-4055
US

V. Phone/Fax

Practice location:
  • Phone: 405-447-9498
  • Fax: 405-447-1911
Mailing address:
  • Phone: 918-492-8200
  • Fax: 918-493-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberK8500225
License Number StateOK

VIII. Authorized Official

Name: SHARON WORSHAM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 918-492-8200