Healthcare Provider Details

I. General information

NPI: 1861928905
Provider Name (Legal Business Name): THE LAUGHING SHARK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 N MAY AVE STE 107
OKLAHOMA CITY OK
73120
US

IV. Provider business mailing address

PO BOX 20326
OKLAHOMA CITY OK
73156-0326
US

V. Phone/Fax

Practice location:
  • Phone: 405-229-3237
  • Fax:
Mailing address:
  • Phone: 405-229-3237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1111
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5258
License Number StateOK

VIII. Authorized Official

Name: DANIELLE J WILLIAMS
Title or Position: OWNER
Credential: M.ED, LPC, LADC/MH
Phone: 405-519-7471