Provider Demographics
NPI:1265663363
Name:CHRYSALIS INSTITUTE, LLC
Entity Type:Organization
Organization Name:CHRYSALIS INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:405-301-3983
Mailing Address - Street 1:800 NE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6302
Mailing Address - Country:US
Mailing Address - Phone:405-735-5263
Mailing Address - Fax:405-735-5265
Practice Address - Street 1:800 NE 19TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6302
Practice Address - Country:US
Practice Address - Phone:405-735-5263
Practice Address - Fax:405-735-5265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty