Healthcare Provider Details

I. General information

NPI: 1659072775
Provider Name (Legal Business Name): DAKOTA SIXKILLER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 S HARVARD AVE
TULSA OK
74114-3300
US

IV. Provider business mailing address

PO BOX 219
GLENPOOL OK
74033-0219
US

V. Phone/Fax

Practice location:
  • Phone: 918-712-4301
  • Fax:
Mailing address:
  • Phone: 918-919-1489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11111
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: