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General NPI Number Information
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NPI Number | 1174072482
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Entity Type | Organization
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Legal Business Name | CROSSROADS 1010 LLC
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Dates
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Enumeration Date | 09/27/2016
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Last Update Date | 11/27/2018
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Provider Practice Location Address
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Address Line | 193908 US HWY 271
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City | ANTLERS
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State | OK
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Zip | 74523
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Country | US
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Telephone | 580-271-7080
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Fax | 580-298-2081
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Provider Business Mailing Address
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Address Line | P.O. BO 1012
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City | ANTLERS
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State | OK
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Zip | 74523
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Country | US
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Telephone | 580-271-7080
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Fax | 580-298-2081
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER GRIFFIN
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Credential | LPC
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Telephone | 580-317-7002
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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 |
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License Number State |
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