Provider Demographics
NPI:1477225217
Name:BEACON BEHAVIORAL HEALTH INC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-383-7609
Mailing Address - Street 1:2208 CLUB HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-6200
Mailing Address - Country:US
Mailing Address - Phone:580-383-7609
Mailing Address - Fax:
Practice Address - Street 1:211 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-4825
Practice Address - Country:US
Practice Address - Phone:405-968-3068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health