Healthcare Provider Details

I. General information

NPI: 1104295500
Provider Name (Legal Business Name): EXCEL MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 S WILLOW ST
PAULS VALLEY OK
73075-3849
US

IV. Provider business mailing address

PO BOX 826
PAULS VALLEY OK
73075-0826
US

V. Phone/Fax

Practice location:
  • Phone: 405-926-2085
  • Fax: 405-926-2089
Mailing address:
  • Phone: 405-926-2085
  • Fax: 405-926-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5643
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1147
License Number StateOK

VIII. Authorized Official

Name: MR. RANDY HUGH GARDENHIRE
Title or Position: CEO
Credential: MS, LPC
Phone: 580-399-3071