Healthcare Provider Details

I. General information

NPI: 1669987830
Provider Name (Legal Business Name): LA VIDA FEARLESS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 UNITED FOUNDERS BLVD STE 124
OKLAHOMA CITY OK
73112-4292
US

IV. Provider business mailing address

3000 UNITED FOUNDERS BLVD STE 124
OKLAHOMA CITY OK
73112-4292
US

V. Phone/Fax

Practice location:
  • Phone: 405-810-5200
  • Fax: 405-493-0700
Mailing address:
  • Phone: 405-810-5200
  • Fax: 405-493-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6158
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DANNY PODOBNIK
Title or Position: MANAGER
Credential:
Phone: 405-810-5200