Basic Information
| Provider Information | |||||||||
| NPI: | 1356859912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGNISON | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 604 CHOCTAW ST | ||||||||
| Address2: | |||||||||
| City: | ALVA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737171626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803271112 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 604 CHOCTAW ST | ||||||||
| Address2: | |||||||||
| City: | ALVA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737171626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803271112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 200749050A | 05 | OK | MEDICAID |