=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588977011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILD AND FAMILY THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2010
-----------------------------------------------------
Last Update Date | 07/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 S BROADWAY BUILDING 1, SUITE 110
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-202-2583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 GLACIER LN
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-202-2583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MS. LOU ANN MOORE
-----------------------------------------------------
Credential | LPC, MED, NCC, NCSC
-----------------------------------------------------
Telephone | 405-202-2583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3207
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------