| Pine Ridge Mental Healthcare, Llc | |
|
8422 N 123rd East Ave Owasso OK 74055-2130 | |
| (918) 858-4353 | |
| Not Available |
| Full Name | Pine Ridge Mental Healthcare, Llc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 8422 N 123rd East Ave, Owasso, Oklahoma |
| Authorized Official Name and Position | Nicole Mason (OWNER) |
| Authorized Official Contact | 6187818686 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Pine Ridge Mental Healthcare, Llc 8422 N 123rd East Ave Owasso OK 74055-2130 Ph: (918) 858-4353 | Pine Ridge Mental Healthcare, Llc 8422 N 123rd East Ave Owasso OK 74055-2130 Ph: (918) 858-4353 |
| NPI Number | 1346828050 |
|---|---|
| Provider Enumeration Date | 04/01/2021 |
| Last Update Date | 12/02/2022 |
| Certification Date | 12/02/2022 |
| Medicare PECOS PAC ID | 2062812043 |
|---|---|
| Medicare Enrollment ID | O20210614000169 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1346828050 | NPI | - | NPPES |
| Provider Name | Ilona Willyard |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1154687697 PECOS PAC ID: 4284088766 Enrollment ID: I20231003000560 |
| Provider Name | Tammy Jo Coletta |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1376766972 PECOS PAC ID: 6507201068 Enrollment ID: I20240223003987 |
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