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General NPI Number Information
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NPI Number | 1750050217
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Entity Type | Organization
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Legal Business Name | BLUE HEAVEN THERAPY, L.L.C.
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Dates
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Enumeration Date | 09/08/2021
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Last Update Date | 09/10/2021
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Provider Practice Location Address
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Address Line | 400 TIMMONS ST.
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City | SEMINOLE
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State | OK
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Zip | 74868
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Country | US
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Telephone | 405-220-7165
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Fax | 405-382-2890
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Provider Business Mailing Address
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Address Line | 1731 LEWIS AVE
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City | SEMINOLE
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State | OK
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Zip | 74868-3615
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Country | US
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Telephone | 405-220-7165
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | JENNIFER L CHEATHAM
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Credential | MSPS, LPC
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Telephone | 405-220-7165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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