Provider Demographics
NPI:1679819106
Name:ADVANCE COUNSELING, PC
Entity Type:Organization
Organization Name:ADVANCE COUNSELING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:405-844-8085
Mailing Address - Street 1:1732 REDLAND DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2453
Mailing Address - Country:US
Mailing Address - Phone:405-844-8085
Mailing Address - Fax:405-285-1652
Practice Address - Street 1:217 W 5TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4056
Practice Address - Country:US
Practice Address - Phone:405-844-8085
Practice Address - Fax:405-285-1652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2578251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200020790HMedicaid