Provider Demographics
NPI:1720400351
Name:PELLEBON, DWAIN A (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:DWAIN
Middle Name:A
Last Name:PELLEBON
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 IOWA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6520
Mailing Address - Country:US
Mailing Address - Phone:405-255-8503
Mailing Address - Fax:405-857-1678
Practice Address - Street 1:2500 BOARDWALK STE 210
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6593
Practice Address - Country:US
Practice Address - Phone:405-857-8357
Practice Address - Fax:405-857-1678
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical