Provider Demographics
NPI:1124560420
Name:BEHAVIORAL MODIFICATION COUNSELING
Entity Type:Organization
Organization Name:BEHAVIORAL MODIFICATION COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:918-808-1000
Mailing Address - Street 1:4308 E 21ST PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-2114
Mailing Address - Country:US
Mailing Address - Phone:919-808-1000
Mailing Address - Fax:
Practice Address - Street 1:4308 E 21ST PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-2114
Practice Address - Country:US
Practice Address - Phone:919-808-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200375600AMedicaid