Provider Demographics
NPI:1295807220
Name:RISENHOOVER, MAVIS WYANEMA (LCSW)
Entity type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:WYANEMA
Last Name:RISENHOOVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
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Mailing Address - Street 1:1101 E MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4815
Mailing Address - Country:US
Mailing Address - Phone:918-426-7800
Mailing Address - Fax:918-426-5526
Practice Address - Street 1:1407 NE D ST
Practice Address - Street 2:SUITE B
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2815
Practice Address - Country:US
Practice Address - Phone:918-967-8491
Practice Address - Fax:918-967-2552
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK31981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical