Provider Demographics
NPI:1528383841
Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Other - Org Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-492-8200
Mailing Address - Street 1:6262 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4055
Mailing Address - Country:US
Mailing Address - Phone:918-492-8200
Mailing Address - Fax:918-492-2849
Practice Address - Street 1:1027 E 66TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3701
Practice Address - Country:US
Practice Address - Phone:918-492-8200
Practice Address - Fax:918-488-0940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCHIATRIC SOLUTIONS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK254873336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy