MEDICARE: MRS. RUE LA SHELLE TENNYSON

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	LPC05122	OK

General Provider Information

NPI Number	:	1609193168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RUE LA SHELLE TENNYSON

Provider Business Mailing Address
First Line	:	15017 KYLE DR UNIT A
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73170-6513
Country	:	US
Telephone Number	:	405-816-2276
Fax Number	:

Provider Business Practice Location Address
First Line	:	3005 NW 63RD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3603
Country	:	US
Telephone Number	:	405-521-1755
Fax Number	:

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

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2026

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