Provider Demographics
NPI:1376786103
Name:DEASON, MICHELLE LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:DEASON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-0027
Mailing Address - Country:US
Mailing Address - Phone:918-207-0378
Mailing Address - Fax:918-207-1661
Practice Address - Street 1:223 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3817
Practice Address - Country:US
Practice Address - Phone:918-507-0711
Practice Address - Fax:918-207-1661
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical