Provider Demographics
NPI:1134366396
Name:KINNISON, MARK DOUGLAS (MED, CRC,LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:KINNISON
Suffix:
Gender:M
Credentials:MED, CRC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5773 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-5723
Mailing Address - Country:US
Mailing Address - Phone:918-241-6705
Mailing Address - Fax:
Practice Address - Street 1:5773 W 1ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-5723
Practice Address - Country:US
Practice Address - Phone:918-241-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional