Healthcare Provider Details

I. General information

NPI: 1811214083
Provider Name (Legal Business Name): MICAH GRANT LANE MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 S LEWIS AVE STE 100
TULSA OK
74136-1019
US

IV. Provider business mailing address

6400 S LEWIS AVE STE 100
TULSA OK
74136-1019
US

V. Phone/Fax

Practice location:
  • Phone: 405-378-2727
  • Fax:
Mailing address:
  • Phone: 405-378-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC05479
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: