Provider Demographics
NPI:1528614377
Name:SALLISAW MENTAL HEALTH LLC
Entity type:Organization
Organization Name:SALLISAW MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-289-0102
Mailing Address - Street 1:7302 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7027
Mailing Address - Country:US
Mailing Address - Phone:918-289-0102
Mailing Address - Fax:
Practice Address - Street 1:204 E CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4604
Practice Address - Country:US
Practice Address - Phone:918-289-0201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty