MEDICARE: DESTINY LYN ELLIS LPC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	10335	OK
2	171M00000X	Case Manager/Care Coordinator
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1790205094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY LYN ELLIS LPC-S

Provider Business Mailing Address
First Line	:	15031 S 4060 RD
Second Line	:
City	:	OOLOGAH
State	:	OK
Zip	:	74053-3737
Country	:	US
Telephone Number	:	918-728-9516
Fax Number	:

Provider Business Practice Location Address
First Line	:	8551 N 125TH EAST AVE STE 250
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-2160
Country	:	US
Telephone Number	:	918-760-5243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2017
Last Update Date	:	04/07/2026

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