Healthcare Provider Details

I. General information

NPI: 1780774976
Provider Name (Legal Business Name): SALLY R WILLIAMS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HENSLEY DR
TAHLEQUAH OK
74464-5264
US

IV. Provider business mailing address

2523 LARRY AVE
TAHLEQUAH OK
74464-5421
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-3000
  • Fax: 918-207-3064
Mailing address:
  • Phone: 918-931-8907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2186
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: