Basic Information
| Provider Information | |||||||||
| NPI: | 1396106639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMEGANO | ||||||||
| FirstName: | OBIANUJU | ||||||||
| MiddleName: | CYNTHIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2613 PATTI PL | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731201769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054734881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6100 S WALKER AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731397026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056344400 | ||||||||
| FaxNumber: | 4056321976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200241240A | 05 | OK | MEDICAID |