Healthcare Provider Details

I. General information

NPI: 1366565905
Provider Name (Legal Business Name): GWYNETTE MARIA CHANEY MS. M.ED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GWYNETTE MARIA CHANEY OLDEN

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E 6TH ST
PAWHUSKA OK
74056-4204
US

IV. Provider business mailing address

124 E 6TH ST
PAWHUSKA OK
74056-4204
US

V. Phone/Fax

Practice location:
  • Phone: 918-604-6054
  • Fax: 918-777-9018
Mailing address:
  • Phone: 918-604-6054
  • Fax: 918-777-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6487
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: