Provider Demographics
NPI:1184743502
Name:WHITTEN, DENNIS DALE (MACJ, LADC, ICAADC)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:DALE
Last Name:WHITTEN
Suffix:
Gender:M
Credentials:MACJ, LADC, ICAADC
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 555
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-0555
Mailing Address - Country:US
Mailing Address - Phone:580-212-9175
Mailing Address - Fax:580-286-6385
Practice Address - Street 1:104 N.E. AVENUE A
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
Practice Address - Country:US
Practice Address - Phone:580-212-9175
Practice Address - Fax:580-286-6385
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0955461203OtherCAADC
OK685OtherICAADC
OK72OtherLICENSED ALCOHOL AND DRUG