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General NPI Number Information
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NPI Number | 1043608508
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE HEALING THERAPEUTIC PRACTICE, LLC
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Dates
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Enumeration Date | 01/06/2015
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Last Update Date | 01/06/2015
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Provider Practice Location Address
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Address Line | 701 W 101ST PL S 818
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City | JENKS
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State | OK
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Zip | 74037-3505
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Country | US
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Telephone | 918-504-5909
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Fax |
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Provider Business Mailing Address
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Address Line | 701 W 101ST PL S 818
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City | JENKS
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State | OK
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Zip | 74037-3505
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/LICENSED PROFESSIONAL
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Name | NICOLE MENYON ROBERSON
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Credential | MHR
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Telephone | 918-504-5909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 5616
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License Number State | OK
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