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General NPI Number Information
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NPI Number | 1528614377
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Entity Type | Organization
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Legal Business Name | SALLISAW MENTAL HEALTH LLC
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Dates
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Enumeration Date | 08/16/2019
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Last Update Date | 08/16/2019
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Provider Practice Location Address
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Address Line | 204 E CHOCTAW AVE
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City | SALLISAW
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State | OK
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Zip | 74955-4604
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Country | US
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Telephone | 918-289-0201
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Fax |
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Provider Business Mailing Address
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Address Line | 7302 S YALE AVE
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City | TULSA
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State | OK
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Zip | 74136-7027
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Country | US
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Telephone | 918-289-0102
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | SHAUNNA FUNSTON
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Credential |
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Telephone | 918-289-0102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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