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General NPI Number Information
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NPI Number | 1780965095
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Entity Type | Organization
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Legal Business Name | STAGES2CHANGE, LLC
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Dates
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Enumeration Date | 08/31/2011
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Last Update Date | 09/07/2011
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Provider Practice Location Address
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Address Line | 1924 LIMESTONE RD
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City | BARTLESVILLE
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State | OK
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Zip | 74006-6714
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Country | US
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Telephone | 918-333-3197
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Fax | 918-333-3197
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Provider Business Mailing Address
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Address Line | 1924 LIMESTONE RD
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City | BARTLESVILLE
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State | OK
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Zip | 74006-6714
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Country | US
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Telephone | 918-333-3197
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Fax | 918-333-3197
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Authorized Official
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Title or Position | OWNER/COUNSELOR
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Name | MRS. SUSAN FAY BUCK
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Credential | LADC
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Telephone | 918-333-3197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 731
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License Number State | OK
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