Healthcare Provider Details

I. General information

NPI: 1437468725
Provider Name (Legal Business Name): CENTER 4 CHANGE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S MAIN ST
MCALESTER OK
74501-5363
US

IV. Provider business mailing address

111 S MAIN ST
MCALESTER OK
74501-5363
US

V. Phone/Fax

Practice location:
  • Phone: 918-694-9677
  • Fax: 918-423-5255
Mailing address:
  • Phone: 918-694-9677
  • Fax: 918-423-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4163
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number133823
License Number StateOK

VIII. Authorized Official

Name: MS. BARBARA J. COUNTZ
Title or Position: PRESIDENT
Credential: M.ED., L.P.C.
Phone: 918-694-9677