Healthcare Provider Details

I. General information

NPI: 1619357936
Provider Name (Legal Business Name): N-SIDEOUT COUNSELING SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N CLASSEN BLVD STE 315
OKLAHOMA CITY OK
73106-6834
US

IV. Provider business mailing address

1330 N CLASSEN BLVD STE 315
OKLAHOMA CITY OK
73106-6834
US

V. Phone/Fax

Practice location:
  • Phone: 405-606-2880
  • Fax: 405-606-2881
Mailing address:
  • Phone: 405-606-2880
  • Fax: 405-606-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5120
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5120
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number5120
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5120
License Number StateOK

VIII. Authorized Official

Name: JEANETTE LOUDERMILK
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 405-606-2880