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General NPI Number Information
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NPI Number | 1669602173
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Entity Type | Organization
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Legal Business Name | EAGLE RIDGE INSTITUTE
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Dates
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Enumeration Date | 07/17/2009
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Last Update Date | 07/17/2009
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Provider Practice Location Address
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Address Line | 1515 W CHICKASAW
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City | SALLISAW
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State | OK
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Zip | 74955
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Country | US
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Telephone | 918-775-4646
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Fax | 405-282-3038
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Provider Business Mailing Address
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Address Line | 601 NE 63 ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73105
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Country | US
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Telephone | 405-282-5283
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Fax | 405-282-3038
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Authorized Official
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Title or Position | ASSOCIATE EXECUTIVE DIRECTOR
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Name | TAMMY M VAUGHN
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Credential | LPC
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Telephone | 405-282-5283
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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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