Healthcare Provider Details

I. General information

NPI: 1861956716
Provider Name (Legal Business Name): MATTHEW LAWRANCE TENNISON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 24TH AVE NW
NORMAN OK
73069-6369
US

IV. Provider business mailing address

1008 24TH AVE NW
NORMAN OK
73069-6369
US

V. Phone/Fax

Practice location:
  • Phone: 405-310-3262
  • Fax:
Mailing address:
  • Phone: 405-310-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21062
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: