=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932710779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SECOND ACT COUNSELING, COACHING AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8904 STANFORD CT
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73132-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-496-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5830 NW EXPRESSWAY, BOX 140
-----------------------------------------------------
City | WARR ACRES
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73132-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-496-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANNA HINSHAW
-----------------------------------------------------
Credential | LPC, LADC
-----------------------------------------------------
Telephone | 405-496-6314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------