Basic Information
| Provider Information | |||||||||
| NPI: | 1588901912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNING | ||||||||
| FirstName: | DENA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 N 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736012614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052190294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10321 N 2274 RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736017521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2013 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3568 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 3568 | 01 | OK | LPC | OTHER |