=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992113955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REACH FOR THE LIGHT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2014
-----------------------------------------------------
Last Update Date | 07/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 LINWOOD BLVD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73106-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-601-0295
-----------------------------------------------------
Fax | 405-601-0316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 LINWOOD BLVD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73106-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-601-0295
-----------------------------------------------------
Fax | 405-601-0316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | CAROLYN J GREENWOOD
-----------------------------------------------------
Credential | LMFT, LADC, ICADC
-----------------------------------------------------
Telephone | 405-601-0295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 516
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 835
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------