Healthcare Provider Details

I. General information

NPI: 1265663363
Provider Name (Legal Business Name): CHRYSALIS INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 NE 19TH ST
MOORE OK
73160-6302
US

IV. Provider business mailing address

800 NE 19TH ST
MOORE OK
73160-6302
US

V. Phone/Fax

Practice location:
  • Phone: 405-735-5263
  • Fax: 405-735-5265
Mailing address:
  • Phone: 405-735-5263
  • Fax: 405-735-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY BENDER
Title or Position: PRESIDENT/THERAPIST
Credential: LPC
Phone: 405-301-3983