Provider Demographics
NPI:1841574589
Name:COMMUNITY COUSELORS GROUP INC.
Entity Type:Organization
Organization Name:COMMUNITY COUSELORS GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BHRS
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLY
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:918-424-5769
Mailing Address - Street 1:113 W ADA AVE
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-2416
Mailing Address - Country:US
Mailing Address - Phone:918-297-3200
Mailing Address - Fax:918-297-3401
Practice Address - Street 1:225 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4307
Practice Address - Country:US
Practice Address - Phone:918-424-5769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========AMedicare PIN