Provider Demographics
NPI:1598192353
Name:MACON, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 N. CINCINNATI AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106
Mailing Address - Country:US
Mailing Address - Phone:918-798-4282
Mailing Address - Fax:
Practice Address - Street 1:2108 N CINCINNATI AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-3717
Practice Address - Country:US
Practice Address - Phone:918-798-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
OK004129260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst