Basic Information
| Provider Information | |||||||||
| NPI: | 1376826321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRESH START COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801 N CLASSEN BLVD | ||||||||
| Address2: | SUITE 159 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731184627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 NW 113TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731146808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052863482 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | ANTWAINE | ||||||||
| AuthorizedOfficialMiddleName: | DARNELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOSOCIAL REHABILITATION SPECIAL | ||||||||
| AuthorizedOfficialTelephone: | 4052743025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.S. BHRS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OK | Y | Agencies | Community/Behavioral Health |
No ID Information.