MEDICARE: MR. KENNETH LYNN GANDY MS, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1738	OK

General Provider Information

NPI Number	:	1225069925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH LYNN GANDY MS, LPC

Provider Business Mailing Address
First Line	:	1300 HOPPE BLVD STE 1
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2319
Country	:	US
Telephone Number	:	580-436-7211
Fax Number	:	580-272-5757

Provider Business Practice Location Address
First Line	:	1300 HOPPE BLVD STE 5
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2319
Country	:	US
Telephone Number	:	580-436-1222
Fax Number	:	580-436-1333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	09/18/2018

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