Provider Demographics
NPI:1720330012
Name:ENID COUNSELING AND DIAGNOSTIC
Entity Type:Organization
Organization Name:ENID COUNSELING AND DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BHRS
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROGGOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-242-5544
Mailing Address - Street 1:230 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4012
Practice Address - Country:US
Practice Address - Phone:580-242-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health