=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457791832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDT COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2013
-----------------------------------------------------
Last Update Date | 06/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6506 STONE VALLEY DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-9558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-226-5273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6506 STONE VALLEY DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-9558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-226-5273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MRS. CANDACE D. TUCKER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-226-5273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 5437
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------