Basic Information
| Provider Information | |||||||||
| NPI: | 1952540304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | LONNA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA,LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2009 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100749080A | 05 | OK | MEDICAID | 100749080C | 05 | OK | MEDICAID |