=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407447725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TATE COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2021
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8906 E SKELLY DR STE J
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74129-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-291-9142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8906 E SKELLY DR STE J
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74129-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-291-9142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DWAYNE REMON TATE
-----------------------------------------------------
Credential | BHRS
-----------------------------------------------------
Telephone | 918-291-9142
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------