=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043051766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGING MINDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8596 E 101ST ST STE D
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-231-0026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8596 E 101ST ST STE D
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-231-0026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | BREANNA WHITE
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 918-231-0026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------