Provider Demographics
NPI:1689919482
Name:FAMILY THERAPY AND RENEWAL CENTER PLLC
Entity Type:Organization
Organization Name:FAMILY THERAPY AND RENEWAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TALITHA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:BACHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-369-4950
Mailing Address - Street 1:6717 S YALE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3328
Mailing Address - Country:US
Mailing Address - Phone:918-369-4950
Mailing Address - Fax:918-369-4951
Practice Address - Street 1:6717 S YALE AVE STE 202
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3328
Practice Address - Country:US
Practice Address - Phone:918-369-4950
Practice Address - Fax:918-369-4951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3728101YP2500X
OK3752101YP2500X
OK982106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200467210AMedicaid