Provider Demographics
NPI:1932845062
Name:HARDESTY, CLINT ERNEST
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:ERNEST
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6369
Mailing Address - Country:US
Mailing Address - Phone:405-310-3262
Mailing Address - Fax:
Practice Address - Street 1:1008 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6369
Practice Address - Country:US
Practice Address - Phone:405-310-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA