Provider Demographics
NPI:1659644979
Name:CROSS, DAN (LADC)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 S REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9466
Mailing Address - Country:US
Mailing Address - Phone:918-260-1096
Mailing Address - Fax:
Practice Address - Street 1:2408 S REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9466
Practice Address - Country:US
Practice Address - Phone:918-260-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK220101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)