Provider Demographics
NPI:1598969800
Name:MAGNESS, TANYA L (LPC, LADC)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:L
Last Name:MAGNESS
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:L
Other - Last Name:COPPENBARGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LADC
Mailing Address - Street 1:300 E WOLF ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446
Mailing Address - Country:US
Mailing Address - Phone:580-730-0168
Mailing Address - Fax:580-872-4661
Practice Address - Street 1:300 E WOLF ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446
Practice Address - Country:US
Practice Address - Phone:580-730-0168
Practice Address - Fax:580-872-4661
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3695101YP2500X
OK845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKSC200463720-AMedicaid