Provider Demographics
NPI:1235672692
Name:RED DIRT MENTAL HEALTH, INC.
Entity Type:Organization
Organization Name:RED DIRT MENTAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICE PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDURE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-370-9614
Mailing Address - Street 1:4330 ADAMS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-1007
Mailing Address - Country:US
Mailing Address - Phone:405-704-8400
Mailing Address - Fax:405-253-0490
Practice Address - Street 1:4330 ADAMS RD STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-1007
Practice Address - Country:US
Practice Address - Phone:405-704-8400
Practice Address - Fax:405-253-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1250103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200677510AMedicaid