1770065930 NPI number — SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC

Table of content: (NPI 1770065930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770065930 NPI number — SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770065930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
832 W. JASPER STREET
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74011-8297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-402-1868
Provider Business Mailing Address Fax Number:
918-994-7903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8304 S KALANCHOE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74011-7808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-417-6087
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DENNIS
Authorized Official First Name:
DARLENE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BUSINESS OWNER/COUSELOR
Authorized Official Telephone Number:
918-402-1868

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  6040 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 6040 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: 6040 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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