Healthcare Provider Details

I. General information

NPI: 1982949061
Provider Name (Legal Business Name): STACIE ELIZABETH COSTA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACIE ELIZABETH CASLER

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7935 E 57TH ST
TULSA OK
74145-8622
US

IV. Provider business mailing address

7935 E 57TH ST
TULSA OK
74145-8622
US

V. Phone/Fax

Practice location:
  • Phone: 918-261-9601
  • Fax: 918-371-0240
Mailing address:
  • Phone: 918-212-8702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5480
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: