Healthcare Provider Details

I. General information

NPI: 1225069925
Provider Name (Legal Business Name): KENNETH LYNN GANDY MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 HOPPE BLVD STE 5
ADA OK
74820-2319
US

IV. Provider business mailing address

1300 HOPPE BLVD STE 1
ADA OK
74820-2319
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-1222
  • Fax: 580-436-1333
Mailing address:
  • Phone: 580-436-7211
  • Fax: 580-272-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1738
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: