Provider Demographics
NPI:1790160224
Name:MAYSE, ANN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:MAYSE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 ROBIN RD.
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604
Mailing Address - Country:US
Mailing Address - Phone:580-763-1624
Mailing Address - Fax:
Practice Address - Street 1:1912 LAKE RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604
Practice Address - Country:US
Practice Address - Phone:580-762-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health