Provider Demographics
NPI:1619130978
Name:EAGLE RIDGE FAMILY TREATMENT CENTER
Entity Type:Organization
Organization Name:EAGLE RIDGE FAMILY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-8272
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1182
Mailing Address - Country:US
Mailing Address - Phone:405-282-8272
Mailing Address - Fax:405-282-3305
Practice Address - Street 1:1916 E PERKINS AVE
Practice Address - Street 2:1916 E PERKINS
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-5804
Practice Address - Country:US
Practice Address - Phone:405-282-8272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE RIDGE INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility