Provider Demographics
NPI:1780201798
Name:CANADIAN COUNTY COLLABORATIVE LLC
Entity Type:Organization
Organization Name:CANADIAN COUNTY COLLABORATIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, RPTS
Authorized Official - Phone:405-805-6203
Mailing Address - Street 1:10616 SW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0445
Mailing Address - Country:US
Mailing Address - Phone:405-805-6203
Mailing Address - Fax:
Practice Address - Street 1:1703 PROFESSIONAL CIR STE 201
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6498
Practice Address - Country:US
Practice Address - Phone:405-805-6203
Practice Address - Fax:405-896-4151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200434450AMedicaid