Provider Demographics
NPI:1235417643
Name:WILLINGHAM, MAGAN MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:MAGAN
Middle Name:MARIE
Last Name:WILLINGHAM
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 1:307 MCGEE CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5950
Mailing Address - Country:US
Mailing Address - Phone:580-212-7064
Mailing Address - Fax:
Practice Address - Street 1:2100 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-5449
Practice Address - Country:US
Practice Address - Phone:580-298-5062
Practice Address - Fax:580-298-9958
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid