Provider Demographics
NPI:1043608508
Name:PROGRESSIVE HEALING THERAPEUTIC PRACTICE, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE HEALING THERAPEUTIC PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MENYON
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MHR
Authorized Official - Phone:918-504-5909
Mailing Address - Street 1:701 W 101ST PL S
Mailing Address - Street 2:818
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W 101ST PL S
Practice Address - Street 2:818
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3505
Practice Address - Country:US
Practice Address - Phone:918-504-5909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty