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General NPI Number Information
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NPI Number | 1013650225
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Entity Type | Individual
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Provider Name | AVERY JOEL FENNELL
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Gender | Male
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Dates
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Enumeration Date | 04/15/2022
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Last Update Date | 04/22/2022
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Provider Practice Location Address
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Address Line | 2617 GENERAL PERSHING BLVD
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City | OKLAHOMA CITY
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State | OK
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Zip | 73107-6437
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Country | US
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Telephone | 405-858-2700
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 12978
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City | OKLAHOMA CITY
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State | OK
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Zip | 73157-2978
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State | OK
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