Healthcare Provider Details

I. General information

NPI: 1215230099
Provider Name (Legal Business Name): HOLLY FAYE WIYNINGER BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 W 3RD ST
ELK CITY OK
73644-4323
US

IV. Provider business mailing address

318 N WEST ST
CORDELL OK
73632-4238
US

V. Phone/Fax

Practice location:
  • Phone: 580-225-5136
  • Fax: 580-225-3477
Mailing address:
  • Phone: 580-660-0670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number080522075
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: