=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710382866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEMENTS OF LIFE COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2014
-----------------------------------------------------
Last Update Date | 10/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1741 W 33RD ST SUITE 100
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-285-5586
-----------------------------------------------------
Fax | 405-562-4858
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1741 W 33RD ST SUITE 100
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-285-5586
-----------------------------------------------------
Fax | 405-562-4858
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. TERRI TARRANT SLACK
-----------------------------------------------------
Credential | LPC, LADC
-----------------------------------------------------
Telephone | 405-401-1464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 638
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4164
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------