Basic Information
Provider Information
NPI: 1821003658
EntityType: 2
ReplacementNPI:  
OrganizationName: PROVIDENCE SERVICE CORPORATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4645 W GORE BLVD
Address2: SUITE 5
City: LAWTON
State: OK
PostalCode: 735056041
CountryCode: US
TelephoneNumber: 5803556800
FaxNumber:  
Practice Location
Address1: 4645 W GORE BLVD
Address2: SUITE 5
City: LAWTON
State: OK
PostalCode: 735056041
CountryCode: US
TelephoneNumber: 5803556800
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/30/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MARTIN
AuthorizedOfficialFirstName: AGLAIA
AuthorizedOfficialMiddleName: 'ALEXIS'
AuthorizedOfficialTitleorPosition: THERAPIST
AuthorizedOfficialTelephone: 5803556800
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: LPC
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251K00000X2560OKY AgenciesPublic Health or Welfare 

No ID Information.


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