MEDICARE: TRANSFORMING LIFE COUNSELING CENTER MID0DEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	4268	OK

General Provider Information

NPI Number	:	1942571732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSFORMING LIFE COUNSELING CENTER MID0DEL

Provider Business Mailing Address
First Line	:	3001 TINKER DIAGONAL ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73115-1017
Country	:	US
Telephone Number	:	405-411-0477
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 TINKER DIAGONAL ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73115-1017
Country	:	US
Telephone Number	:	405-411-0477
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MRS. LADONNA WHITE
Credential	:	MA, LPC
Telephone Number	:	405-410-4770

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	02/29/2012

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