Healthcare Provider Details

I. General information

NPI: 1477166296
Provider Name (Legal Business Name): SUNDANCE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13413 E 106TH ST N
OWASSO OK
74055-5910
US

IV. Provider business mailing address

PO BOX 1194
OWASSO OK
74055-1194
US

V. Phone/Fax

Practice location:
  • Phone: 918-928-2601
  • Fax:
Mailing address:
  • Phone: 918-928-2601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY STEWART
Title or Position: OWNER
Credential: PC
Phone: 918-928-2601