Provider Demographics
NPI:1740548387
Name:PRINCIPLES OF RESILIENCE OF YOUTH DEVELOPMENT, LLC
Entity type:Organization
Organization Name:PRINCIPLES OF RESILIENCE OF YOUTH DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MHR
Authorized Official - Phone:405-840-1243
Mailing Address - Street 1:2828 NW 57TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6814
Mailing Address - Country:US
Mailing Address - Phone:405-840-1243
Mailing Address - Fax:405-840-1211
Practice Address - Street 1:2828 NW 57TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6814
Practice Address - Country:US
Practice Address - Phone:405-840-1243
Practice Address - Fax:405-840-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management