Healthcare Provider Details

I. General information

NPI: 1205031002
Provider Name (Legal Business Name): LISA STAIRES POTTORF M.ED., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 S SHERIDAN RD STE 117
TULSA OK
74145-1101
US

IV. Provider business mailing address

4525 S. IRVINGTON AVE.
TULSA OK
74135
US

V. Phone/Fax

Practice location:
  • Phone: 918-794-6570
  • Fax: 918-340-5189
Mailing address:
  • Phone: 918-832-7764
  • Fax: 918-832-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2224
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: