Basic Information
| Provider Information | |||||||||
| NPI: | 1376848283 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LCDA | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | NEW BEGUINING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 SW 10TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731095610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052360701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2624 N ANN ARBOR AVE APT 209 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731271805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056018075 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2011 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAS | ||||||||
| AuthorizedOfficialFirstName: | ROSSANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CASE MANAGER, BHRS | ||||||||
| AuthorizedOfficialTelephone: | 4056018075 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MED | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OK | N | Agencies | Case Management | 251S00000X | OK | Y | Agencies | Community/Behavioral Health |
No ID Information.