Provider Demographics
NPI:1922142454
Name:OBANA, EDWARD R JR (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:OBANA
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 W 78TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2622
Mailing Address - Country:US
Mailing Address - Phone:918-284-7653
Mailing Address - Fax:
Practice Address - Street 1:1311 FORT STREET, SUITE J
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923
Practice Address - Country:US
Practice Address - Phone:479-452-5040
Practice Address - Fax:479-452-5047
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR905-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S453Medicare PIN