Provider Demographics
NPI:1669987830
Name:LA VIDA FEARLESS COUNSELING
Entity type:Organization
Organization Name:LA VIDA FEARLESS COUNSELING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PODOBNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-810-5200
Mailing Address - Street 1:3000 UNITED FOUNDERS BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4292
Mailing Address - Country:US
Mailing Address - Phone:405-810-5200
Mailing Address - Fax:405-493-0700
Practice Address - Street 1:3000 UNITED FOUNDERS BLVD STE 124
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4292
Practice Address - Country:US
Practice Address - Phone:405-810-5200
Practice Address - Fax:405-493-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
OK6158251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200748610AMedicaid