Healthcare Provider Details

I. General information

NPI: 1225947047
Provider Name (Legal Business Name): ANNE ILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S SERVICE RD APT 1701
MOORE OK
73160-5589
US

IV. Provider business mailing address

2900 S SERVICE RD APT 1701
MOORE OK
73160-5589
US

V. Phone/Fax

Practice location:
  • Phone: 405-245-3475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12357
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: