=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265663363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRYSALIS INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2009
-----------------------------------------------------
Last Update Date | 08/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 NE 19TH ST
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-735-5263
-----------------------------------------------------
Fax | 405-735-5265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 NE 19TH ST
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-735-5263
-----------------------------------------------------
Fax | 405-735-5265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/THERAPIST
-----------------------------------------------------
Name | MRS. KELLY BENDER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-301-3983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------