=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376967216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENKILLER BEHAVIORAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2014
-----------------------------------------------------
Last Update Date | 02/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W MAPLE ST
-----------------------------------------------------
City | STILWELL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74960-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-797-7786
-----------------------------------------------------
Fax | 918-696-8679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27753 S WELLING RD
-----------------------------------------------------
City | WELLING
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74471-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-797-7786
-----------------------------------------------------
Fax | 918-457-4104
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | KRISTA MICHELLE ROACH
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 918-797-7786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------