Provider Demographics
NPI:1629127840
Name:CHRISTIAN CLINIC FOR COUNSELING, INC
Entity Type:Organization
Organization Name:CHRISTIAN CLINIC FOR COUNSELING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:CRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-942-8888
Mailing Address - Street 1:2311 KILEY WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3428
Mailing Address - Country:US
Mailing Address - Phone:405-942-8888
Mailing Address - Fax:999-999-9999
Practice Address - Street 1:3832 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2820
Practice Address - Country:US
Practice Address - Phone:405-928-8888
Practice Address - Fax:999-999-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK203851000OtherMAGELLAN HEALTH SERVICES
OK=========001OtherBLUE CROSS BLUE SHIELD
OK500522067Medicare UPIN
OK=========001OtherBLUE CROSS BLUE SHIELD
OK203851000OtherMAGELLAN HEALTH SERVICES