Healthcare Provider Details

I. General information

NPI: 1215401708
Provider Name (Legal Business Name): ELLISA LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SPENCER RD
SPENCER OK
73084-3649
US

IV. Provider business mailing address

2601 SPENCER RD
SPENCER OK
73084-3649
US

V. Phone/Fax

Practice location:
  • Phone: 405-824-6432
  • Fax:
Mailing address:
  • Phone: 405-824-6432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8248
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8248
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: