Provider Demographics
NPI:1780929752
Name:RISE PLLC
Entity type:Organization
Organization Name:RISE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LPC,LADC
Authorized Official - Phone:918-448-0590
Mailing Address - Street 1:311 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4047
Mailing Address - Country:US
Mailing Address - Phone:918-465-0909
Mailing Address - Fax:918-465-0404
Practice Address - Street 1:311 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4047
Practice Address - Country:US
Practice Address - Phone:918-465-0909
Practice Address - Fax:918-465-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN/AMedicaid