Healthcare Provider Details

I. General information

NPI: 1063809291
Provider Name (Legal Business Name): KENMORE CLAXTON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIMOTHY CLAXTON

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 S MINGO RD STE 101
TULSA OK
74133-5721
US

IV. Provider business mailing address

9228 S MINGO RD STE 101
TULSA OK
74133-5721
US

V. Phone/Fax

Practice location:
  • Phone: 405-378-2727
  • Fax:
Mailing address:
  • Phone: 405-378-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10877
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: