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General NPI Number Information
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NPI Number | 1699102640
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Entity Type | Organization
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Legal Business Name | LIFE VISION
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Dates
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Enumeration Date | 10/07/2013
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Last Update Date | 10/07/2013
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Provider Practice Location Address
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Address Line | 2101 N ASH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-1106
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Country | US
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Telephone | 580-716-4787
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Fax |
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Provider Business Mailing Address
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Address Line | 11605 S Q ST
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City | PONCA CITY
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State | OK
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Zip | 74601-7565
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Country | US
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Telephone | 580-716-4787
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | TERA BIAGGI
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Credential | LCSW
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Telephone | 580-716-4787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 3696
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License Number State | OK
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