Healthcare Provider Details

I. General information

NPI: 1134637937
Provider Name (Legal Business Name): MARISSA OPAL MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 E SKELLY DR # 400B
TULSA OK
74105-6358
US

IV. Provider business mailing address

3105 E SKELLY DR # 400B
TULSA OK
74105-6358
US

V. Phone/Fax

Practice location:
  • Phone: 918-591-3071
  • Fax: 918-615-2261
Mailing address:
  • Phone: 918-591-3071
  • Fax: 918-615-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017044142
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12384
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number03359
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: