Provider Demographics
NPI:1720303134
Name:EATHERLY, JOSEPH ROBERT (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:EATHERLY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49500 CR E 1600
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74872
Mailing Address - Country:US
Mailing Address - Phone:580-320-5633
Mailing Address - Fax:
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1723
Practice Address - Country:US
Practice Address - Phone:580-371-3019
Practice Address - Fax:580-371-0138
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5004101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor