Provider Demographics
NPI:1780915207
Name:ENNIS, RACHIEL ANN (LPC UNDERSUPERVISION)
Entity type:Individual
Prefix:
First Name:RACHIEL
Middle Name:ANN
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LPC UNDERSUPERVISION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 S GEORGE NIGH EXPY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7400
Mailing Address - Country:US
Mailing Address - Phone:918-470-7069
Mailing Address - Fax:918-302-0405
Practice Address - Street 1:721 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7400
Practice Address - Country:US
Practice Address - Phone:918-470-7069
Practice Address - Fax:918-302-0405
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580AMedicaid