Healthcare Provider Details

I. General information

NPI: 1679357719
Provider Name (Legal Business Name): CHARLES HEITLAND LPC U/S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

1708 SUMAC DR
NORMAN OK
73071-1945
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5100
  • Fax:
Mailing address:
  • Phone: 580-399-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11686
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: