Healthcare Provider Details

I. General information

NPI: 1346828050
Provider Name (Legal Business Name): PINE RIDGE MENTAL HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 01/26/2025
Certification Date: 01/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8418 N 123RD EAST AVE
OWASSO OK
74055-2139
US

IV. Provider business mailing address

8418 N 123RD EAST AVE
OWASSO OK
74055-2139
US

V. Phone/Fax

Practice location:
  • Phone: 918-858-4353
  • Fax:
Mailing address:
  • Phone: 918-858-4353
  • Fax: 866-246-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE MASON
Title or Position: OWNER
Credential: PA
Phone: 618-781-8686