Healthcare Provider Details

I. General information

NPI: 1396602884
Provider Name (Legal Business Name): MS. AMANDA RENAE LILE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 N PENIEL AVE STE 500
BETHANY OK
73008-3402
US

IV. Provider business mailing address

9608 SULTANS WATER WAY
YUKON OK
73099-7894
US

V. Phone/Fax

Practice location:
  • Phone: 405-603-3265
  • Fax:
Mailing address:
  • Phone: 405-603-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: