Basic Information
| Provider Information | |||||||||
| NPI: | 1124311485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY IMPACT YOUTH & FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95751 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731435751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058635724 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4209 NW 23RD ST. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058635724 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | PATTERSON | ||||||||
| AuthorizedOfficialFirstName: | LARRENDA | ||||||||
| AuthorizedOfficialMiddleName: | DEANEISHA | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4058635724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS, LADCU/S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.