Healthcare Provider Details

I. General information

NPI: 1124379110
Provider Name (Legal Business Name): KIMBERLY MCCUTCHEON MHR, LPC, CCTP-II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17520 THUNDERBIRD HILLS RD
NEWALLA OK
74857-9438
US

IV. Provider business mailing address

17520 THUNDERBIRD HILLS RD
NEWALLA OK
74857-9438
US

V. Phone/Fax

Practice location:
  • Phone: 405-481-3022
  • Fax:
Mailing address:
  • Phone: 405-481-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC05726
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLPC05726
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC05726
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: