Provider Demographics
NPI:1225640337
Name:GANNAWAY, MICHELLE DAVIS (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAVIS
Last Name:GANNAWAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13315 N COLTRANE RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8257
Mailing Address - Country:US
Mailing Address - Phone:405-570-4603
Mailing Address - Fax:
Practice Address - Street 1:13315 N COLTRANE RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8257
Practice Address - Country:US
Practice Address - Phone:405-570-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2837101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional