1750050217 NPI number — BLUE HEAVEN THERAPY, L.L.C.

Table of content: (NPI 1750050217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750050217 NPI number — BLUE HEAVEN THERAPY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE HEAVEN THERAPY, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JENNIFER CHEATHAM, LPC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750050217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1731 LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEMINOLE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74868-3615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-220-7165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 TIMMONS ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEMINOLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-220-7165
Provider Business Practice Location Address Fax Number:
405-382-2890
Provider Enumeration Date:
09/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CHEATHAM
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
405-220-7165

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200723390B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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