Healthcare Provider Details

I. General information

NPI: 1518718782
Provider Name (Legal Business Name): DESIRE EARTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 E 2ND ST
EDMOND OK
73034-5307
US

IV. Provider business mailing address

1050 E 2ND ST # 233
EDMOND OK
73034-5313
US

V. Phone/Fax

Practice location:
  • Phone: 405-414-5418
  • Fax:
Mailing address:
  • Phone: 405-414-5418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: DESIREE JONES
Title or Position: CEO
Credential: LPC
Phone: 405-885-2558