Provider Demographics
NPI:1992205140
Name:FLETCHER, VONDY C (MS, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:VONDY
Middle Name:C
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2860
Mailing Address - Country:US
Mailing Address - Phone:702-907-0741
Mailing Address - Fax:539-367-5088
Practice Address - Street 1:504 W ATLANTA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7004
Practice Address - Country:US
Practice Address - Phone:702-907-0741
Practice Address - Fax:539-367-5088
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI0334103K00000X
OK10010101YP2500X
NVCP1269103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV145600645Medicaid