Provider Demographics
NPI:1144527227
Name:RIVERSIDE BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:RIVERSIDE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLININCAL AND OUTPATIENT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:918-855-2031
Mailing Address - Street 1:4618 S 31ST WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-7532
Mailing Address - Country:US
Mailing Address - Phone:662-419-9786
Mailing Address - Fax:
Practice Address - Street 1:4618 S 31ST WEST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-7532
Practice Address - Country:US
Practice Address - Phone:662-419-9786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801081083323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility