Provider Demographics
NPI:1255959508
Name:FAISON, XANDER (CMII,LPC)
Entity type:Individual
Prefix:
First Name:XANDER
Middle Name:
Last Name:FAISON
Suffix:
Gender:F
Credentials:CMII,LPC
Other - Prefix:
Other - First Name:XANDER
Other - Middle Name:DANIEL
Other - Last Name:FAISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:4512 SUNNYVIEW DR APT 178
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-3163
Mailing Address - Country:US
Mailing Address - Phone:443-991-1582
Mailing Address - Fax:
Practice Address - Street 1:7917 N MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-4540
Practice Address - Country:US
Practice Address - Phone:405-938-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6684101YP2500X
171M00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK98754852Medicaid