Basic Information
| Provider Information | |||||||||
| NPI: | 1831409440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR PSYCHOLOGICAL DEVELOPMENT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 142 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809202069 | ||||||||
| FaxNumber: | 5809201010 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809202069 | ||||||||
| FaxNumber: | 5809201010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5809202069 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBS, LPC-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251S00000X | N | Agencies | Community/Behavioral Health | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.