Healthcare Provider Details

I. General information

NPI: 1396284725
Provider Name (Legal Business Name): OWASSO BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10306 N 138TH EAST AVE STE 206
OWASSO OK
74055-4665
US

IV. Provider business mailing address

10306 N 138TH EAST AVE STE 206
OWASSO OK
74055-4665
US

V. Phone/Fax

Practice location:
  • Phone: 918-636-5597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4043
License Number StateOK

VIII. Authorized Official

Name: KRISTA QUIGLEY
Title or Position: OWNER/LPC
Credential:
Phone: 918-636-5597