Basic Information
| Provider Information | |||||||||
| NPI: | 1629127840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN CLINIC FOR COUNSELING, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2311 KILEY WAY | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730343428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059428888 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3832 N MERIDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059288888 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | CRUSE | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | RONALD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4059428888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 156 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 203851000 | 01 | OK | MAGELLAN HEALTH SERVICES | OTHER |