Healthcare Provider Details

I. General information

NPI: 1659781649
Provider Name (Legal Business Name): FUNDAMENTALS COUNSELING SERVICES,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 HWY 59 #4
WESTVILLE OK
74965
US

IV. Provider business mailing address

994 N MOSELEY RD
COLCORD OK
74338-3383
US

V. Phone/Fax

Practice location:
  • Phone: 918-723-3735
  • Fax: 918-723-3730
Mailing address:
  • Phone: 479-228-1120
  • Fax: 918-723-3730

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: AMY RUSK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-228-1120