Healthcare Provider Details

I. General information

NPI: 1073626545
Provider Name (Legal Business Name): LARA MAE MATTOX PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 EAST SKELLY DRIVE SUITE 305
TULSA OK
74105-6317
US

IV. Provider business mailing address

3015 EAST SKELLY DRIVE SUITE 305
TULSA OK
74105-6317
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-4866
  • Fax: 918-392-4867
Mailing address:
  • Phone: 918-392-4866
  • Fax: 918-392-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06-09P
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1022
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: