Provider Demographics
NPI:1639699267
Name:LASTING CHANGE THERAPY LLC
Entity Type:Organization
Organization Name:LASTING CHANGE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAI-AN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:405-237-5782
Mailing Address - Street 1:10600 S PENN AVE STE 16-915
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-4256
Mailing Address - Country:US
Mailing Address - Phone:405-237-5782
Mailing Address - Fax:
Practice Address - Street 1:10600 S PENN AVE STE 16-915
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4256
Practice Address - Country:US
Practice Address - Phone:405-237-5782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-24
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4691261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1508169533Medicaid