Healthcare Provider Details

I. General information

NPI: 1063731834
Provider Name (Legal Business Name): MISTY B ELLERBY LPC CANDIDATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S. OKLAHOMA
LANGSTON OK
73050
US

IV. Provider business mailing address

PO BOX 754
LANGSTON OK
73050-0754
US

V. Phone/Fax

Practice location:
  • Phone: 405-326-6102
  • Fax:
Mailing address:
  • Phone: 405-326-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: