Healthcare Provider Details

I. General information

NPI: 1215293220
Provider Name (Legal Business Name): DEDICATED OUTPATIENT THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920770 DEER RIDGE LN
WELLSTON OK
74881-8146
US

IV. Provider business mailing address

920770 DEER RIDGE LN
WELLSTON OK
74881-8146
US

V. Phone/Fax

Practice location:
  • Phone: 405-650-7278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2206
License Number StateOK

VIII. Authorized Official

Name: JILL M BASHORUN
Title or Position: OWNER
Credential: LPC
Phone: 405-650-7278