Provider Demographics
NPI:1528442878
Name:COMMUNITY IMPACT YOUTH & FAMILY SERVICE
Entity type:Organization
Organization Name:COMMUNITY IMPACT YOUTH & FAMILY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC/LADC
Authorized Official - Phone:405-455-6738
Mailing Address - Street 1:7901 NE 10TH ST STE B103
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3653
Mailing Address - Country:US
Mailing Address - Phone:405-455-6738
Mailing Address - Fax:
Practice Address - Street 1:4909 SE 86TH TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-6315
Practice Address - Country:US
Practice Address - Phone:405-455-6738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK103K00000XMedicaid