Healthcare Provider Details

I. General information

NPI: 1639843980
Provider Name (Legal Business Name): CALVIN JACOB ELMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9424 N MAY AVE
OKLAHOMA CITY OK
73120-2712
US

IV. Provider business mailing address

11213 NILE AVE
OKLAHOMA CITY OK
73114-7071
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-8851
  • Fax:
Mailing address:
  • Phone: 405-240-2481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCCANDIDATE13689
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: