Healthcare Provider Details

I. General information

NPI: 1922246115
Provider Name (Legal Business Name): PENNINGTON CREEK LIFE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S MICHIGAN ST STE B
COALGATE OK
74538-2825
US

IV. Provider business mailing address

PO BOX 261
FITTSTOWN OK
74842-0261
US

V. Phone/Fax

Practice location:
  • Phone: 580-310-4164
  • Fax:
Mailing address:
  • Phone: 580-310-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3877
License Number StateOK

VIII. Authorized Official

Name: MRS. JAN M WYATT
Title or Position: CLINICAL DIRECTOR
Credential: MS LPC
Phone: 580-310-4164