Healthcare Provider Details

I. General information

NPI: 1407781644
Provider Name (Legal Business Name): LIFE CHANGE OUTPATIENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14400 BOGERT PKWY STE 600
OKLAHOMA CITY OK
73134-2652
US

IV. Provider business mailing address

14400 BOGERT PKWY STE 600
OKLAHOMA CITY OK
73134-2652
US

V. Phone/Fax

Practice location:
  • Phone: 405-252-0823
  • Fax:
Mailing address:
  • Phone: 405-252-0823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARA MCBRIDE
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 334-498-5707