Healthcare Provider Details

I. General information

NPI: 1588942015
Provider Name (Legal Business Name): PRIVATE PSYCHIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 S DETROIT AVE STE 1075
TULSA OK
74120-4276
US

IV. Provider business mailing address

4845 S SHERIDAN RD 504
TULSA OK
74145-5751
US

V. Phone/Fax

Practice location:
  • Phone: 918-856-3436
  • Fax: 877-245-1779
Mailing address:
  • Phone: 918-856-3436
  • Fax: 877-245-1779

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 Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SELENA MELANESE PARKS
Title or Position: CEO
Credential:
Phone: 405-708-6999