Provider Demographics
NPI:1194034983
Name:LIFE VISION COUNSELING SERVICES, PLLC
Entity Type:Organization
Organization Name:LIFE VISION COUNSELING SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:405-503-0490
Mailing Address - Street 1:3035 NW 63RD ST
Mailing Address - Street 2:230
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3632
Mailing Address - Country:US
Mailing Address - Phone:405-242-5342
Mailing Address - Fax:405-529-6972
Practice Address - Street 1:3035 NW 63RD ST
Practice Address - Street 2:230
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3632
Practice Address - Country:US
Practice Address - Phone:405-242-5342
Practice Address - Fax:405-529-6972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2458101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200306260AMedicaid