=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336617422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRISTONE COUNSELING & DEVELOPMENTAL STRATEGIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 FAIRVIEW AVE STE 1
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-304-9447
-----------------------------------------------------
Fax | 580-304-7217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 FAIRVIEW AVE STE 1
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-304-9447
-----------------------------------------------------
Fax | 580-304-7217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LEAD THERAPIST
-----------------------------------------------------
Name | MRS. ANA BEETS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 580-304-9447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------