Healthcare Provider Details

I. General information

NPI: 1790377711
Provider Name (Legal Business Name): ADVANCED PRACTICE MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 NW 23RD ST
OKLAHOMA CITY OK
73106-1202
US

IV. Provider business mailing address

3409 STONE BROOK CT
OKLAHOMA CITY OK
73120-0812
US

V. Phone/Fax

Practice location:
  • Phone: 405-627-2830
  • Fax:
Mailing address:
  • Phone: 405-627-2830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURIE ANN RAY
Title or Position: MANAGER/OWNER
Credential: PA-C, CAQ PSYCH,LCSW
Phone: 405-833-1108