Provider Demographics
NPI:1003586157
Name:MAYES, GLENANNETTA (LPC-C, BSN, RN)
Entity Type:Individual
Prefix:MRS
First Name:GLENANNETTA
Middle Name:
Last Name:MAYES
Suffix:
Gender:F
Credentials:LPC-C, BSN, RN
Other - Prefix:MRS
Other - First Name:GLENNETTA
Other - Middle Name:
Other - Last Name:MAYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-C, BSN, RN
Mailing Address - Street 1:1402 MAXEY DR
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1101
Mailing Address - Country:US
Mailing Address - Phone:918-616-6968
Mailing Address - Fax:
Practice Address - Street 1:1402 MAXEY DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1101
Practice Address - Country:US
Practice Address - Phone:918-616-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0089870163WC0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201128730BMedicaid