Healthcare Provider Details

I. General information

NPI: 1871744797
Provider Name (Legal Business Name): THE LIFE CONNECTION COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7145 S BRADEN AVE
TULSA OK
74136-6302
US

IV. Provider business mailing address

7145 S BRADEN AVE
TULSA OK
74136-6302
US

V. Phone/Fax

Practice location:
  • Phone: 918-496-9588
  • Fax:
Mailing address:
  • Phone: 918-496-9588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number614
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3782
License Number StateOK

VIII. Authorized Official

Name: MR. R. BRENT SHARPE
Title or Position: DIRECTOR
Credential: LPC, LMFT
Phone: 918-496-9588