Provider Demographics
NPI:1982847885
Name:HENSON, STACY RENEE (MED, LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RENEE
Last Name:HENSON
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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:PADEN
Mailing Address - State:OK
Mailing Address - Zip Code:74860-0280
Mailing Address - Country:US
Mailing Address - Phone:405-826-5271
Mailing Address - Fax:
Practice Address - Street 1:1414 N KENNEDY AVE STE 111
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-4761
Practice Address - Country:US
Practice Address - Phone:405-878-7400
Practice Address - Fax:405-878-5558
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3947101YP2500X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool