Provider Demographics
NPI:1376875377
Name:RATZLAFF, TYSON BENJAMIN (LPC)
Entity Type:Individual
Prefix:MR
First Name:TYSON
Middle Name:BENJAMIN
Last Name:RATZLAFF
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 1:2355 E CEDAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-4045
Mailing Address - Country:US
Mailing Address - Phone:580-272-8012
Mailing Address - Fax:580-371-2056
Practice Address - Street 1:705 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1734
Practice Address - Country:US
Practice Address - Phone:580-371-3799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health