Basic Information
| Provider Information | |||||||||
| NPI: | 1366565905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANEY | ||||||||
| FirstName: | GWYNETTE | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS. M.ED, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHANEY OLDEN | ||||||||
| OtherFirstName: | GWYNETTE | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PAWHUSKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740564204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186046054 | ||||||||
| FaxNumber: | 9187779018 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PAWHUSKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740564204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186046054 | ||||||||
| FaxNumber: | 9187779018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 6487 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.