Provider Demographics
NPI:1780975375
Name:CHRYSALIS HEALTH SERVICES P.C.
Entity type:Organization
Organization Name:CHRYSALIS HEALTH SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-230-1183
Mailing Address - Street 1:3033 NORTH WALNUT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105
Mailing Address - Country:US
Mailing Address - Phone:405-230-1183
Mailing Address - Fax:
Practice Address - Street 1:3033 N WALNUT AVE
Practice Address - Street 2:WEST BUILDING, 2ND FLOOR (MIRAWORX)
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2832
Practice Address - Country:US
Practice Address - Phone:405-230-1183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty