=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225695653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTRINSIC HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 05/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 N BROOKLINE AVE STE 630
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-688-5526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 N BROOKLINE AVE STE 630
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-688-5526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MR. ZACHARY RAE JOHNSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 918-688-5526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------