Healthcare Provider Details

I. General information

NPI: 1538495692
Provider Name (Legal Business Name): MARTI LEEANN NICHOLS LBHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56577 COUNTY ROAD 660
COLCORD OK
74338-2520
US

IV. Provider business mailing address

56577 COUNTY ROAD 660
COLCORD OK
74338-2520
US

V. Phone/Fax

Practice location:
  • Phone: 918-864-0353
  • Fax:
Mailing address:
  • Phone: 918-864-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1274
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: