Provider Demographics
NPI:1164640249
Name:HEDDLESTEN, KENNETH REX (LPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:REX
Last Name:HEDDLESTEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-2824
Mailing Address - Country:US
Mailing Address - Phone:405-247-9777
Mailing Address - Fax:405-247-9778
Practice Address - Street 1:102 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-2824
Practice Address - Country:US
Practice Address - Phone:405-247-9777
Practice Address - Fax:405-247-9778
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1961101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1961OtherLPC NUMBER