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General NPI Number Information
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NPI Number | 1003025990
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Entity Type | Organization
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Legal Business Name | THUNDER CANYON COUNSELING CENTER, INC.
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 10/28/2013
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Provider Practice Location Address
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Address Line | 1911 LOCUST ST
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City | ALVA
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State | OK
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Zip | 73717-1759
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Country | US
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Telephone | 580-327-3846
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Fax |
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Provider Business Mailing Address
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Address Line | 1911 LOCUST ST
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City | ALVA
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State | OK
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Zip | 73717-1759
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Country | US
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Telephone | 580-327-3846
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. MARK WILLIAM DAVIS
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Credential | PH.D.
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Telephone | 580-327-3846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1107
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License Number State | OK
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