Healthcare Provider Details

I. General information

NPI: 1003726373
Provider Name (Legal Business Name): LIVE WELL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SE 4TH ST STE C
MOORE OK
73160-6831
US

IV. Provider business mailing address

501 SE 4TH ST STE C
MOORE OK
73160-6831
US

V. Phone/Fax

Practice location:
  • Phone: 405-693-1159
  • Fax:
Mailing address:
  • Phone: 405-693-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY HARLESS
Title or Position: THERAPIST
Credential: LPC-S
Phone: 405-693-1159