Provider Demographics
NPI:1750050217
Name:BLUE HEAVEN THERAPY, L.L.C.
Entity Type:Organization
Organization Name:BLUE HEAVEN THERAPY, L.L.C.
Other - Org Name:JENNIFER CHEATHAM, LPC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSPS, LPC
Authorized Official - Phone:405-220-7165
Mailing Address - Street 1:1731 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-3615
Mailing Address - Country:US
Mailing Address - Phone:405-220-7165
Mailing Address - Fax:
Practice Address - Street 1:400 TIMMONS ST.
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868
Practice Address - Country:US
Practice Address - Phone:405-220-7165
Practice Address - Fax:405-382-2890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200723390BMedicaid