Provider Demographics
NPI:1003025990
Name:THUNDER CANYON COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:THUNDER CANYON COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-327-3846
Mailing Address - Street 1:1911 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-1759
Mailing Address - Country:US
Mailing Address - Phone:580-327-3846
Mailing Address - Fax:
Practice Address - Street 1:1911 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-1759
Practice Address - Country:US
Practice Address - Phone:580-327-3846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1107251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health