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General NPI Number Information
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NPI Number | 1265786651
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Entity Type | Organization
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Legal Business Name | SHAMROCK BEHAVIORAL HEALTH SERVICES OF OKLAHOMA, LLC
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Dates
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Enumeration Date | 11/06/2012
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Last Update Date | 11/06/2012
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Provider Practice Location Address
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Address Line | 1600 E US HIGHWAY 66 SUITE #5
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City | EL RENO
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State | OK
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Zip | 73036-5787
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Country | US
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Telephone | 405-464-3279
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Fax |
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Provider Business Mailing Address
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Address Line | 12309 NEWGATE DR
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City | YUKON
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State | OK
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Zip | 73099-6426
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Country | US
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Telephone | 405-464-3279
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Fax |
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Authorized Official
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Title or Position | OWNER - THERAPIST
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Name | MR. KELLY DALE GROVES
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Credential | LPC, NCC
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Telephone | 405-464-3279
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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