Provider Demographics
NPI:1538402979
Name:LIFESPAN
Entity type:Organization
Organization Name:LIFESPAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-931-9901
Mailing Address - Street 1:212 W EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 W EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4710
Practice Address - Country:US
Practice Address - Phone:580-931-9901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health