Provider Demographics
NPI:1376656850
Name:WHERTVINE, LISA M (MS,LPC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:WHERTVINE
Suffix:
Gender:F
Credentials:MS,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MAIN ST STE 324
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6322
Mailing Address - Country:US
Mailing Address - Phone:580-226-9222
Mailing Address - Fax:580-226-9226
Practice Address - Street 1:301 W MAIN ST STE 324
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6322
Practice Address - Country:US
Practice Address - Phone:580-226-9222
Practice Address - Fax:580-226-9226
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1777101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional