Provider Demographics
NPI:1770895112
Name:CHANDLER, HOLLY R (MBS, LBP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:R
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:MBS, LBP
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 74
Mailing Address - Street 2:
Mailing Address - City:PADEN
Mailing Address - State:OK
Mailing Address - Zip Code:74860-0074
Mailing Address - Country:US
Mailing Address - Phone:405-249-4361
Mailing Address - Fax:918-623-2334
Practice Address - Street 1:120 S 4TH ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-3802
Practice Address - Country:US
Practice Address - Phone:918-623-1199
Practice Address - Fax:918-623-2334
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0176101YM0800X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health