Healthcare Provider Details

I. General information

NPI: 1225520638
Provider Name (Legal Business Name): ECCLESIA COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10306 N 138TH EAST AVE STE 200
OWASSO OK
74055-4665
US

IV. Provider business mailing address

8324 N QUEBEC AVE
SPERRY OK
74073-4741
US

V. Phone/Fax

Practice location:
  • Phone: 918-671-7764
  • Fax:
Mailing address:
  • Phone: 918-671-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6365
License Number StateOK

VIII. Authorized Official

Name: PERCY CALVERT III
Title or Position: OWNER AND LPC
Credential: LPC
Phone: 918-671-7764