Provider Demographics
NPI:1770065930
Name:SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC
Entity type:Organization
Organization Name:SUI GENERIS COUNSELING AND LIFE CARE SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER/COUSELOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:918-402-1868
Mailing Address - Street 1:832 W. JASPER STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-8297
Mailing Address - Country:US
Mailing Address - Phone:918-402-1868
Mailing Address - Fax:918-994-7903
Practice Address - Street 1:8304 S KALANCHOE AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-7808
Practice Address - Country:US
Practice Address - Phone:918-417-6087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60401041C0700X, 251B00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty