Basic Information
| Provider Information | |||||||||
| NPI: | 1629469754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE CLINICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 SW F AVE | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735014506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805957000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 807 SW F AVE | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735014506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805957000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | WEARY | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 5805833320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.