Basic Information
| Provider Information | |||||||||
| NPI: | 1558714741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNINGSEN | ||||||||
| FirstName: | CORBIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057736470 | ||||||||
| FaxNumber: | 4057736463 | ||||||||
| Practice Location | |||||||||
| Address1: | 5915 W MEMORIAL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731422022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057736470 | ||||||||
| FaxNumber: | 4057736463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2016 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6725 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | N/A | 01 | OK | BCBS, TRI-CARE, MAGELLAN | OTHER |