Provider Demographics
NPI:1912398322
Name:WHALEN THERAPEUTIC CENTER PLLC
Entity Type:Organization
Organization Name:WHALEN THERAPEUTIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC LCPC
Authorized Official - Phone:918-200-9691
Mailing Address - Street 1:10306 N 138TH EAST AVE
Mailing Address - Street 2:STE. 206
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4665
Mailing Address - Country:US
Mailing Address - Phone:918-200-9691
Mailing Address - Fax:888-975-3464
Practice Address - Street 1:10306 N 138TH EAST AVE
Practice Address - Street 2:STE. 206
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4665
Practice Address - Country:US
Practice Address - Phone:918-200-9691
Practice Address - Fax:888-975-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-07
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5538101YM0800X, 101YP2500X
KS2394101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200402920BMedicaid
OK200575340AMedicaid
KS201122950AMedicaid