Provider Demographics
NPI:1629334388
Name:PROFESSIONAL COUNSELING ASSOCIATES OF MCCURTAIN COUNTY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL COUNSELING ASSOCIATES OF MCCURTAIN COUNTY, INC.
Other - Org Name:FULL LIFE FAMILY RESOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLYNIS
Authorized Official - Middle Name:WATKINS
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-584-2478
Mailing Address - Street 1:RR 2 BOX 6090
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-9808
Mailing Address - Country:US
Mailing Address - Phone:580-236-2376
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3975
Practice Address - Country:US
Practice Address - Phone:580-584-2478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty