Provider Demographics
NPI:1760850150
Name:SWINFORD, THEEA D (MS, LPC)
Entity Type:Individual
Prefix:
First Name:THEEA
Middle Name:D
Last Name:SWINFORD
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1048
Mailing Address - Country:US
Mailing Address - Phone:580-436-7120
Mailing Address - Fax:580-436-7120
Practice Address - Street 1:2100 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1048
Practice Address - Country:US
Practice Address - Phone:580-436-7120
Practice Address - Fax:580-436-7121
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health