Provider Demographics
NPI:1699020974
Name:CROSSROADS COUNSELING OF SOUTHEAST OKLAHOMA, PLLC
Entity Type:Organization
Organization Name:CROSSROADS COUNSELING OF SOUTHEAST OKLAHOMA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:918-497-8859
Mailing Address - Street 1:620 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3016
Mailing Address - Country:US
Mailing Address - Phone:580-364-0170
Mailing Address - Fax:580-364-0170
Practice Address - Street 1:620 E COURT ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3016
Practice Address - Country:US
Practice Address - Phone:580-364-0170
Practice Address - Fax:580-364-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3710251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health