Basic Information
Provider Information | |||||||||
NPI: | 1518152529 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ | ||||||||
FirstName: | TAMI | ||||||||
MiddleName: | RANAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MHR LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TALLEY | ||||||||
OtherFirstName: | TAMI | ||||||||
OtherMiddleName: | RANAE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 358 | ||||||||
Address2: | 527 WEST THIRD ST | ||||||||
City: | KONAWA | ||||||||
State: | OK | ||||||||
PostalCode: | 74849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809252362 | ||||||||
Practice Location | |||||||||
Address1: | 527 WEST THIRD ST | ||||||||
Address2: |   | ||||||||
City: | KONAWA | ||||||||
State: | OK | ||||||||
PostalCode: | 74849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809252362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2007 | ||||||||
LastUpdateDate: | 02/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3125 | OK | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 3125 | 01 | OK | OK STATE DEPT OF HLTH | OTHER |