Provider Demographics
NPI:1346828050
Name:PINE RIDGE MENTAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PINE RIDGE MENTAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:618-781-8686
Mailing Address - Street 1:8422 N 123RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2130
Mailing Address - Country:US
Mailing Address - Phone:918-858-4353
Mailing Address - Fax:866-246-2942
Practice Address - Street 1:8422 N 123RD EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2130
Practice Address - Country:US
Practice Address - Phone:918-858-4353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-01
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty