Provider Demographics
NPI:1821291428
Name:DALLAS, WAYNE F (LPC, LADC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:F
Last Name:DALLAS
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 FOUNTAIN VW
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2618
Mailing Address - Country:US
Mailing Address - Phone:405-348-6349
Mailing Address - Fax:
Practice Address - Street 1:5131 N CLASSEN BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5258
Practice Address - Country:US
Practice Address - Phone:405-767-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional