Provider Demographics
NPI:1083163083
Name:RESTORE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:RESTORE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MED,LPC
Authorized Official - Phone:405-919-1817
Mailing Address - Street 1:2212 WESTPARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4098
Mailing Address - Country:US
Mailing Address - Phone:405-919-1817
Mailing Address - Fax:
Practice Address - Street 1:2212 WESTPARK DR STE 105
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-4098
Practice Address - Country:US
Practice Address - Phone:405-919-1817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-02
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty