Provider Demographics
NPI: | 1467570101 |
---|---|
Name: | EDMOND FAMILY COUNSELING, INC. |
Entity Type: | Organization |
Organization Name: | EDMOND FAMILY COUNSELING, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | JACKIE |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | SHAW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LPC, LMFT |
Authorized Official - Phone: | 405-341-3554 |
Mailing Address - Street 1: | 1251 N BROADWAY |
Mailing Address - Street 2: | SUITE C |
Mailing Address - City: | EDMOND |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 73034-3616 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 405-341-3554 |
Mailing Address - Fax: | 405-341-3511 |
Practice Address - Street 1: | 1251 N BROADWAY |
Practice Address - Street 2: | SUITE C |
Practice Address - City: | EDMOND |
Practice Address - State: | OK |
Practice Address - Zip Code: | 73034-3616 |
Practice Address - Country: | US |
Practice Address - Phone: | 405-341-3554 |
Practice Address - Fax: | 405-341-3511 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-27 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |