Provider Demographics
NPI:1649549338
Name:SOUTH PEORIA NEIGHBORHOOD CONNECTION FOUNDATION
Entity type:Organization
Organization Name:SOUTH PEORIA NEIGHBORHOOD CONNECTION FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANNY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENDICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMFT
Authorized Official - Phone:918-830-1523
Mailing Address - Street 1:1208 E 58TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-8401
Mailing Address - Country:US
Mailing Address - Phone:918-742-5597
Mailing Address - Fax:918-742-4485
Practice Address - Street 1:1208 E 58TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-8401
Practice Address - Country:US
Practice Address - Phone:918-742-5597
Practice Address - Fax:918-742-4485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-25
Last Update Date:2011-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK328251S00000X
OK296251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1508994138Medicaid
OK100723970BMedicaid