Healthcare Provider Details

I. General information

NPI: 1528442878
Provider Name (Legal Business Name): COMMUNITY IMPACT YOUTH & FAMILY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 SE 86TH TER
OKLAHOMA CITY OK
73135-6315
US

IV. Provider business mailing address

7901 NE 10TH ST STE B103
MIDWEST CITY OK
73110-3653
US

V. Phone/Fax

Practice location:
  • Phone: 405-455-6738
  • Fax:
Mailing address:
  • Phone: 405-455-6738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOK

VIII. Authorized Official

Name: LARRENDA D PATTERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, LPC/LADC
Phone: 405-455-6738