Healthcare Provider Details

I. General information

NPI: 1144760638
Provider Name (Legal Business Name): BLUE HAVEN COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 KELSEY DR
EDMOND OK
73013-5322
US

IV. Provider business mailing address

3028 KELSEY DR
EDMOND OK
73013-5322
US

V. Phone/Fax

Practice location:
  • Phone: 405-205-6572
  • Fax:
Mailing address:
  • Phone: 405-205-6572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6090
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6090
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6090
License Number StateOK

VIII. Authorized Official

Name: MRS. REBECCA CAY JONES
Title or Position: OWNER
Credential: M.ED., LPC
Phone: 405-205-6572