Healthcare Provider Details

I. General information

NPI: 1033076872
Provider Name (Legal Business Name): SEAN MICHAEL LORD M.DIV, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 E 14TH ST
TULSA OK
74104-4412
US

IV. Provider business mailing address

8415 S 111TH EAST AVE
TULSA OK
74133-2565
US

V. Phone/Fax

Practice location:
  • Phone: 918-918-1416
  • Fax:
Mailing address:
  • Phone: 918-918-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: