Provider Demographics
NPI:1124311485
Name:COMMUNITY IMPACT YOUTH & FAMILY SERVICES
Entity type:Organization
Organization Name:COMMUNITY IMPACT YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LARRENDA
Authorized Official - Middle Name:DEANEISHA
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LADCU/S
Authorized Official - Phone:405-863-5724
Mailing Address - Street 1:PO BOX 95751
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-5751
Mailing Address - Country:US
Mailing Address - Phone:405-863-5724
Mailing Address - Fax:
Practice Address - Street 1:4209 NW 23RD ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107
Practice Address - Country:US
Practice Address - Phone:405-863-5724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management