Provider Demographics
NPI:1578102588
Name:DREADFULWATER, ELIZABETH ROSE (LPC-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:DREADFULWATER
Suffix:
Gender:F
Credentials:LPC-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ROSE
Other - Last Name:DREADFULWATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BHA
Mailing Address - Street 1:716 S 2ND ST # 1014
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-4806
Mailing Address - Country:US
Mailing Address - Phone:918-696-6212
Mailing Address - Fax:
Practice Address - Street 1:716 S 2ND ST # 1014
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-4806
Practice Address - Country:US
Practice Address - Phone:918-696-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor