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General NPI Number Information
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NPI Number | 1780201798
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Entity Type | Organization
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Legal Business Name | CANADIAN COUNTY COLLABORATIVE LLC
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Dates
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Enumeration Date | 06/26/2020
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Last Update Date | 06/26/2020
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Provider Practice Location Address
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Address Line | 1703 PROFESSIONAL CIR STE 201
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City | YUKON
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State | OK
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Zip | 73099-6498
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Country | US
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Telephone | 405-805-6203
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Fax | 405-896-4151
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Provider Business Mailing Address
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Address Line | 10616 SW 35TH ST
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City | YUKON
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State | OK
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Zip | 73099-0445
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Country | US
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Telephone | 405-805-6203
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MATT PIERCE
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Credential | LPC, RPTS
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Telephone | 405-805-6203
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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 |
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License Number State |
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