Healthcare Provider Details

I. General information

NPI: 1831664077
Provider Name (Legal Business Name): HEART MIND & SOUL COUNSELING AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W MAIN ST STE 302
ARDMORE OK
73401-6322
US

IV. Provider business mailing address

301 W MAIN ST STE 302
ARDMORE OK
73401-6322
US

V. Phone/Fax

Practice location:
  • Phone: 580-319-5264
  • Fax: 844-769-4938
Mailing address:
  • Phone: 580-319-5264
  • Fax: 844-769-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. TRIPR STEMMONS SELF
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-319-5264