| Organization Name: | PROGRESSIVE HEALING THERAPEUTIC PRACTICE, LLC |
| NPI Number: | 1043608508 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICOLE MENYON ROBERSON (OWNER/LICENSED PROFESSIONAL) |
| Mailing Address: | 701 W 101st Pl S 818 Jenks |
| State: | OK US |
| Postal Code: | 740373505 |
| Phone Number: | 9185045909 |
| Fax Number: | |
| NPI Enumeration Date: | 01/06/2015 |
| NPI Last Update Date: | 01/06/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 5616 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |