Provider Demographics
NPI:1316283203
Name:RHOADES, ELTON JR
Entity type:Individual
Prefix:
First Name:ELTON
Middle Name:
Last Name:RHOADES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 S LEXINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4223
Mailing Address - Country:US
Mailing Address - Phone:405-315-5464
Mailing Address - Fax:
Practice Address - Street 1:527 NW 23RD ST STE 250
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-1515
Practice Address - Country:US
Practice Address - Phone:405-606-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor