Provider Demographics
NPI:1417291824
Name:VANN, DAVID LEE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:VANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7744 S VICTOR AVE # C
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7722
Mailing Address - Country:US
Mailing Address - Phone:580-230-1543
Mailing Address - Fax:
Practice Address - Street 1:7744 S VICTOR AVE # C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7722
Practice Address - Country:US
Practice Address - Phone:580-230-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X, 101YP2500X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst