Provider Demographics
NPI:1598060675
Name:BEHAVIORAL HEALTH SERVICES OF GREEN COUNTRY
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH SERVICES OF GREEN COUNTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKISON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-476-0501
Mailing Address - Street 1:463 SW 579 LOOP BLDG B
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-2885
Mailing Address - Country:US
Mailing Address - Phone:918-476-0501
Mailing Address - Fax:
Practice Address - Street 1:463 SW 579 LOOP BLDG B
Practice Address - Street 2:
Practice Address - City:CHOUTEAU
Practice Address - State:OK
Practice Address - Zip Code:74337-2885
Practice Address - Country:US
Practice Address - Phone:918-476-0501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200315410AMedicaid