=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528429347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAKING CYCLES INC.,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 03/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3160 S. 129TH E AVE SUITE 130
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74134-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-409-0536
-----------------------------------------------------
Fax | 918-414-7602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1821 N. CHEYENNE AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74106-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-356-8581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO/THERAPIST
-----------------------------------------------------
Name | DEON DUPREE WHITESIDE
-----------------------------------------------------
Credential | M.S., LPC
-----------------------------------------------------
Telephone | 209-356-8581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5915
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------