Organization
PENNINGTON CREEK LIFE HOUSE
Active
Organization
PENNINGTON CREEK LIFE HOUSE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JAN M WYATT MS LPC (CLINICAL DIRECTOR)
(580) 310-4164
Entity
Organization
Contact information
Practice address
8 S MICHIGAN ST STE B, COALGATE, OK 74538-2825
(580) 310-4164
Mailing address
PO BOX 261, FITTSTOWN, OK 74842-0261
(580) 310-4164
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
3877
OK
Other
Enumeration date
01/27/2009
Last updated
01/27/2009
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