Healthcare Provider Details

I. General information

NPI: 1912086026
Provider Name (Legal Business Name): BRENT D OBANNON LPC, LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S TRAVIS ST 303
SHERMAN TX
75090-5990
US

IV. Provider business mailing address

521 CARRIAGE ESTATES RD
SHERMAN TX
75092-4425
US

V. Phone/Fax

Practice location:
  • Phone: 903-813-0723
  • Fax: 903-813-5452
Mailing address:
  • Phone: 903-868-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13223
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: