Healthcare Provider Details

I. General information

NPI: 1124037288
Provider Name (Legal Business Name): SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 S SHERIDAN RD
TULSA OK
74133-4055
US

IV. Provider business mailing address

6262 S SHERIDAN RD
TULSA OK
74133-4055
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-8200
  • Fax: 918-493-3268
Mailing address:
  • Phone: 918-492-8200
  • Fax: 918-493-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateOK

VIII. Authorized Official

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