Provider Demographics
NPI:1811416977
Name:WETHRIVE COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:WETHRIVE COUNSELING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:918-809-4841
Mailing Address - Street 1:416 E B ST APT A
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4157
Mailing Address - Country:US
Mailing Address - Phone:918-809-4841
Mailing Address - Fax:
Practice Address - Street 1:416 E B ST APT A
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4157
Practice Address - Country:US
Practice Address - Phone:918-809-4841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164767496OtherINDIVIDUAL NPI