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General NPI Number Information
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NPI Number | 1205353455
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Entity Type | Organization
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Legal Business Name | BA WELLNESS SERVICES, LLC
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Dates
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Enumeration Date | 08/28/2017
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Last Update Date | 08/17/2023
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Provider Practice Location Address
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Address Line | 100 W MAIN ST FL 4
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City | PAWHUSKA
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State | OK
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Zip | 74056-4149
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Country | US
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Telephone | 918-287-5420
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Fax | 918-287-5234
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Provider Business Mailing Address
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Address Line | 604 HICKORY DR
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City | CLEVELAND
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State | OK
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Zip | 74020-1002
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Country | US
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Telephone | 918-850-6503
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Fax |
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Authorized Official
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Title or Position | LLC OWNER MANAGER
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Name | DAVID RAY CORDLE JR.
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Credential | LPC
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Telephone | 539-260-6873
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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 | 5951
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License Number State | OK
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