Healthcare Provider Details

I. General information

NPI: 1982920583
Provider Name (Legal Business Name): CHARLES CORBIN HUMBLE MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 07/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 N PENIEL AVE STE 500
BETHANY OK
73008-3402
US

IV. Provider business mailing address

3908 N PENIEL AVE STE 500
BETHANY OK
73008-3402
US

V. Phone/Fax

Practice location:
  • Phone: 405-808-7180
  • Fax:
Mailing address:
  • Phone: 405-808-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3981
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: