Healthcare Provider Details

I. General information

NPI: 1023369642
Provider Name (Legal Business Name): ABUNDANT GRACE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 E 81ST ST STE 5125
TULSA OK
74137-4213
US

IV. Provider business mailing address

2448 E 81ST ST STE 5125
TULSA OK
74137-4213
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-7875
  • Fax: 800-260-7966
Mailing address:
  • Phone: 918-392-7875
  • Fax: 800-260-7966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANALISA NIETO PENA
Title or Position: CEO
Credential: LPC CANDIDATE
Phone: 918-269-9511