Provider Demographics
NPI:1730583402
Name:IMPACT COUNSELING CENTER LLC
Entity type:Organization
Organization Name:IMPACT COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHALON
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:405-306-0465
Mailing Address - Street 1:PO BOX 2206
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-2206
Mailing Address - Country:US
Mailing Address - Phone:405-872-8461
Mailing Address - Fax:405-872-8466
Practice Address - Street 1:115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-9596
Practice Address - Country:US
Practice Address - Phone:405-872-8461
Practice Address - Fax:405-872-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK955101YM0800X, 101YP2500X, 106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty