Provider Demographics
NPI:1922483627
Name:CONSULTING AND COUNSELING FOR COMMUNITY CHANGE, PLLC
Entity Type:Organization
Organization Name:CONSULTING AND COUNSELING FOR COMMUNITY CHANGE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:KEEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, LADC/MH
Authorized Official - Phone:918-901-9300
Mailing Address - Street 1:1313 CATHY AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6609
Mailing Address - Country:US
Mailing Address - Phone:918-772-8466
Mailing Address - Fax:
Practice Address - Street 1:2021 MAHANEY AVE STE 4
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5795
Practice Address - Country:US
Practice Address - Phone:918-901-9300
Practice Address - Fax:918-901-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3992251S00000X
OK606251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health