Provider Demographics
NPI:1447821293
Name:GREEN COUNTRY MENTAL HEALTH & THERAPEUTIC SERVICES, PLC
Entity type:Organization
Organization Name:GREEN COUNTRY MENTAL HEALTH & THERAPEUTIC SERVICES, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC-S, RPT
Authorized Official - Phone:539-323-0125
Mailing Address - Street 1:5914 S 130TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-2391
Mailing Address - Country:US
Mailing Address - Phone:539-323-0125
Mailing Address - Fax:
Practice Address - Street 1:4325 E 51ST ST STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3646
Practice Address - Country:US
Practice Address - Phone:539-302-9192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200420780AMedicaid