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General NPI Number Information
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NPI Number | 1346828050
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Entity Type | Organization
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Legal Business Name | PINE RIDGE MENTAL HEALTHCARE, LLC
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Dates
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Enumeration Date | 04/01/2021
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Last Update Date | 01/26/2025
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Provider Practice Location Address
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Address Line | 8418 N 123RD EAST AVE
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City | OWASSO
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State | OK
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Zip | 74055-2139
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Country | US
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Telephone | 918-858-4353
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Fax |
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Provider Business Mailing Address
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Address Line | 8418 N 123RD EAST AVE
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City | OWASSO
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State | OK
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Zip | 74055-2139
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Country | US
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Telephone | 918-858-4353
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Fax | 866-246-2942
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Authorized Official
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Title or Position | OWNER
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Name | DR. NICOLE MASON
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Credential | PA
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Telephone | 618-781-8686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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