Provider Demographics
NPI:1154608164
Name:RAY, CONNIE M (LPC)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:M
Last Name:RAY
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 1:2104-A N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-658-4016
Mailing Address - Fax:
Practice Address - Street 1:123 E AVENUE C STE B
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-2603
Practice Address - Country:US
Practice Address - Phone:918-658-4016
Practice Address - Fax:866-318-8057
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-05
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1302101YA0400X
101YM0800X, 101Y00000X
OK6213101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1154608164Medicaid