Provider Demographics
NPI:1699158683
Name:WHITE HORSE RANCH OUTPATIENT, LLC
Entity type:Organization
Organization Name:WHITE HORSE RANCH OUTPATIENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:580-571-1272
Mailing Address - Street 1:40803 S COUNTY ROAD 213
Mailing Address - Street 2:1601 WILKIE ROAD
Mailing Address - City:MOORELAND
Mailing Address - State:OK
Mailing Address - Zip Code:73852-9131
Mailing Address - Country:US
Mailing Address - Phone:580-994-5649
Mailing Address - Fax:580-994-5972
Practice Address - Street 1:40803 S COUNTY ROAD 213
Practice Address - Street 2:1601 WILKIE ROAD
Practice Address - City:MOORELAND
Practice Address - State:OK
Practice Address - Zip Code:73852-9131
Practice Address - Country:US
Practice Address - Phone:580-994-5649
Practice Address - Fax:580-994-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4974101YM0800X
OK839251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty