Basic Information
| Provider Information | |||||||||
| NPI: | 1790989895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | CONNER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERND | ||||||||
| OtherFirstName: | PENNY | ||||||||
| OtherMiddleName: | WATSON | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1509 W 108TH ST S | ||||||||
| Address2: | |||||||||
| City: | JENKS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740372641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186943399 | ||||||||
| FaxNumber: | 9184991598 | ||||||||
| Practice Location | |||||||||
| Address1: | 7010 S YALE AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741365743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184922552 | ||||||||
| FaxNumber: | 9184991598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 614 | OK | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.