Provider Demographics
NPI:1083919179
Name:KENNISON, TERESA WILIE (MS, LPC-CANDIDATE)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:WILIE
Last Name:KENNISON
Suffix:
Gender:F
Credentials:MS, LPC-CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S MULDROW ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3278
Mailing Address - Country:US
Mailing Address - Phone:580-579-3620
Mailing Address - Fax:
Practice Address - Street 1:1350 S MULDROW ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3278
Practice Address - Country:US
Practice Address - Phone:580-579-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst