=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922646645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANQUILITY COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2019
-----------------------------------------------------
Last Update Date | 01/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N MERIDIAN AVE STE 406
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73107-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-818-5049
-----------------------------------------------------
Fax | 833-597-8370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20200 N HARRAH RD
-----------------------------------------------------
City | LUTHER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73054-9707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-818-5049
-----------------------------------------------------
Fax | 833-597-8370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MS. ANGELA MATOS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-818-5049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------