Provider Demographics
NPI:1376826321
Name:FRESH START COUNSELING SERVICES
Entity Type:Organization
Organization Name:FRESH START COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOSOCIAL REHABILITATION SPECIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTWAINE
Authorized Official - Middle Name:DARNELL
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:MS BHRS
Authorized Official - Phone:405-274-3025
Mailing Address - Street 1:4801 N CLASSEN BLVD
Mailing Address - Street 2:SUITE 159
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4627
Mailing Address - Country:US
Mailing Address - Phone:405-607-6670
Mailing Address - Fax:
Practice Address - Street 1:509 NW 113TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6808
Practice Address - Country:US
Practice Address - Phone:405-286-3482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health