Healthcare Provider Details

I. General information

NPI: 1770065930
Provider Name (Legal Business Name): SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8304 S KALANCHOE AVE
BROKEN ARROW OK
74011-7808
US

IV. Provider business mailing address

832 W. JASPER STREET SUITE B
BROKEN ARROW OK
74011-8297
US

V. Phone/Fax

Practice location:
  • Phone: 918-417-6087
  • Fax:
Mailing address:
  • Phone: 918-402-1868
  • Fax: 918-994-7903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6040
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6040
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6040
License Number StateOK

VIII. Authorized Official

Name: DARLENE A DENNIS
Title or Position: BUSINESS OWNER/COUSELOR
Credential: LCSW
Phone: 918-402-1868