Healthcare Provider Details

I. General information

NPI: 1578061578
Provider Name (Legal Business Name): LIFE MIND , PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 E 22ND PL
TULSA OK
74114-3131
US

IV. Provider business mailing address

2624 E 22ND PL
TULSA OK
74114-3131
US

V. Phone/Fax

Practice location:
  • Phone: 918-760-1098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number4777
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4777
License Number StateOK

VIII. Authorized Official

Name: LINDA BARNUM
Title or Position: THERAPIST
Credential: LPC
Phone: 918-760-1098