Provider Demographics
NPI:1164939765
Name:PERSONAL REVOLUTIONS BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:PERSONAL REVOLUTIONS BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HALTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:405-550-2688
Mailing Address - Street 1:6801 S WESTERN AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1816
Mailing Address - Country:US
Mailing Address - Phone:405-550-2688
Mailing Address - Fax:405-619-3924
Practice Address - Street 1:6801 S WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1816
Practice Address - Country:US
Practice Address - Phone:405-550-2688
Practice Address - Fax:405-619-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2003754400BMedicaid
OK200781380AMedicaid