Provider Demographics
NPI:1124338298
Name:CHANCE, MARY KRISTINA (LADC, LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KRISTINA
Last Name:CHANCE
Suffix:
Gender:F
Credentials:LADC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-2201
Mailing Address - Country:US
Mailing Address - Phone:918-253-2550
Mailing Address - Fax:918-253-2122
Practice Address - Street 1:2485 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-2201
Practice Address - Country:US
Practice Address - Phone:918-253-2550
Practice Address - Fax:918-253-2122
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK814101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)