Provider Demographics
NPI:1992012983
Name:BENNETT, GINA BETH (LPC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:BETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ECHO LN
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-9654
Mailing Address - Country:US
Mailing Address - Phone:405-698-7399
Mailing Address - Fax:
Practice Address - Street 1:2912 S DOUGLAS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-7179
Practice Address - Country:US
Practice Address - Phone:405-698-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-12
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3593101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional