Provider Demographics
NPI:1841544863
Name:KINNISON, BRENDA KAY (MHR)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAY
Last Name:KINNISON
Suffix:
Gender:F
Credentials:MHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W MAIN ST STE 140230
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6326
Mailing Address - Country:US
Mailing Address - Phone:580-224-2929
Mailing Address - Fax:866-777-7906
Practice Address - Street 1:333 W MAIN ST STE 140230
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6326
Practice Address - Country:US
Practice Address - Phone:580-224-2929
Practice Address - Fax:866-777-7906
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK06629101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health