MEDICARE: COMMUNITY ADOLESCENT REHABILITATIVE EFFORT FOR CHANGE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	261QM0804X	OK
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578690137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY ADOLESCENT REHABILITATIVE EFFORT FOR CHANGE INC

Provider Business Mailing Address
First Line	:	3621 N KELLEY AVE
Second Line	:	STE 100
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-4520
Country	:	US
Telephone Number	:	405-524-5525
Fax Number	:	405-524-5528

Provider Business Practice Location Address
First Line	:	3621 N KELLEY AVE
Second Line	:	STE 100
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-4520
Country	:	US
Telephone Number	:	405-524-5525
Fax Number	:	405-524-5528

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. CALETTA MCPHERSON
Credential	:
Telephone Number	:	405-524-5525

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/03/2008

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1609078880 — MRS. JOAN CRAFT JOHNSON
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1699979013 — GWENDOLYN R. LEWIS B.A.
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1497959878 — MS. CALETTA MCPHERSON MHR, LADC
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1174718951 — THOMAS GRIFFITH BA
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Directions to “COMMUNITY ADOLESCENT REHABILITATIVE EFFORT FOR CHANGE INC ” Practice Location

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