Healthcare Provider Details

I. General information

NPI: 1336789601
Provider Name (Legal Business Name): DEDRA ANN HANSBRO LPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

2240 W MICKEY DR
MUSTANG OK
73064-4043
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: