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General NPI Number Information
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NPI Number | 1629334388
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL COUNSELING ASSOCIATES OF MCCURTAIN COUNTY, INC.
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Dates
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Enumeration Date | 04/06/2012
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Last Update Date | 04/06/2012
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Provider Practice Location Address
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Address Line | 205 MAIN ST
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City | BROKEN BOW
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State | OK
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Zip | 74728-3975
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Country | US
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Telephone | 580-584-2478
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Fax |
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Provider Business Mailing Address
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Address Line | RR 2 BOX 6090
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City | BROKEN BOW
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State | OK
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Zip | 74728-9808
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Country | US
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Telephone | 580-236-2376
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLYNIS WATKINS DANIEL
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Credential | LPC
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Telephone | 580-584-2478
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 3881
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License Number State | OK
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