Provider Demographics
NPI:1083850564
Name:CRAIG, TESSA JANE (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:JANE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 NW MILLER RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5956
Mailing Address - Country:US
Mailing Address - Phone:580-492-5085
Mailing Address - Fax:
Practice Address - Street 1:1719 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-7305
Practice Address - Country:US
Practice Address - Phone:580-581-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4042101YP2500X
101YS0200X
OK930106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool