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General NPI Number Information
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NPI Number | 1114332442
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Entity Type | Organization
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Legal Business Name | CLAY CROSSING FOUNDATION
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Dates
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Enumeration Date | 06/25/2014
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Last Update Date | 06/25/2014
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Provider Practice Location Address
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Address Line | 32018 HIGHWAY 59
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City | MAUD
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State | OK
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Zip | 74854
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Country | US
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Telephone | 866-374-1220
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8
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City | MAUD
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State | OK
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Zip | 74854-0008
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Country | US
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Telephone | 186-637-4120
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BRET LEIKER
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Credential | CRADC, LAC
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Telephone | 866-374-1220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 956
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 10000000
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License Number State | OK
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