Organization
INTEGRATED RENEGADE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PETRA RUSSELL LPC (OWNER)
(918) 321-0697
Entity
Organization
Contact information
Practice address
1264 E 139TH PL, GLENPOOL, OK 74033-3125
(918) 321-0697
Mailing address
1264 E 139TH PL, GLENPOOL, OK 74033-3125
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
10/09/2023
Last updated
10/09/2023
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