=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477216059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TD BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2021
-----------------------------------------------------
Last Update Date | 10/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2227 S GARNETT RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74129-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-595-2555
-----------------------------------------------------
Fax | 479-595-2555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2227 S GARNETT RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74129-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-595-2555
-----------------------------------------------------
Fax | 479-595-2555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. LANCE DOUGLAS DRAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-595-2555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------