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General NPI Number Information
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NPI Number | 1952881427
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Entity Type | Organization
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Legal Business Name | EMBRACE LIFE COUNSELING LLC
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Dates
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Enumeration Date | 08/15/2018
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Last Update Date | 08/15/2018
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Provider Practice Location Address
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Address Line | 10306 N 138TH EAST AVE STE 206
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City | OWASSO
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State | OK
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Zip | 74055-4679
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Country | US
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Telephone | 918-212-6196
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Fax | 918-520-1202
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Provider Business Mailing Address
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Address Line | 10306 N 138TH EAST AVE STE 206
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City | OWASSO
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State | OK
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Zip | 74055-4679
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Country | US
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Telephone | 918-212-6196
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Fax | 918-520-1202
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Authorized Official
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Title or Position | LPC AND OWNER
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Name | KIMBERLY PETTY
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Credential | LPC
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Telephone | 918-212-6196
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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 | 5565
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License Number State | OK
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