Provider Demographics
NPI:1407154933
Name:PROJECT IMPACT OKLAHOMA LLC
Entity type:Organization
Organization Name:PROJECT IMPACT OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KIMBRO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:580-677-9406
Mailing Address - Street 1:102 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-2202
Mailing Address - Country:US
Mailing Address - Phone:580-677-9406
Mailing Address - Fax:
Practice Address - Street 1:102 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-2202
Practice Address - Country:US
Practice Address - Phone:580-677-9406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3839251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health