Provider Demographics
NPI:1063784692
Name:STREET, GENNA SUE (LPC)
Entity type:Individual
Prefix:MRS
First Name:GENNA
Middle Name:SUE
Last Name:STREET
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 N 379 RD
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-6232
Mailing Address - Country:US
Mailing Address - Phone:405-379-2823
Mailing Address - Fax:
Practice Address - Street 1:3324 N 379 RD
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-6232
Practice Address - Country:US
Practice Address - Phone:405-379-2823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3029101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health