Provider Demographics
NPI:1740384049
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 SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WORSHAM
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:918-493-3268
Practice Address - Street 1:6125 S SHERIDAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4056
Practice Address - Country:US
Practice Address - Phone:918-585-3083
Practice Address - Fax:918-492-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)