Healthcare Provider Details

I. General information

NPI: 1598321440
Provider Name (Legal Business Name): TIBA COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 NW 63RD ST STE 305
OKLAHOMA CITY OK
73116-1504
US

IV. Provider business mailing address

3801 NW 63RD ST STE 137
OKLAHOMA CITY OK
73116-1921
US

V. Phone/Fax

Practice location:
  • Phone: 405-234-6804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ASHLEY BRYANT
Title or Position: DIRECTOR
Credential: MS
Phone: 405-234-6804