=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376123646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALM MIND MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2021
-----------------------------------------------------
Last Update Date | 05/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8596 E 101ST ST STE D
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-370-6939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8596 E 101ST ST STE D
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | LACY DEANE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 830-370-6939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------