Healthcare Provider Details

I. General information

NPI: 1134349582
Provider Name (Legal Business Name): DOROTHY LYNETTE MILLICAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DOROTHY LYNETTE MILLICAN-WYNN PH.D.

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/13/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

THE ELITE MEDICAL CLINIC 3336 E 32ND STREET
TULSA OK
74135-4448
US

IV. Provider business mailing address

P.O. BOX 52135 DOROTHY MILLICAN
TULSA OK
74152-0135
US

V. Phone/Fax

Practice location:
  • Phone: 918-740-4066
  • Fax: 918-670-7364
Mailing address:
  • Phone: 918-740-4066
  • Fax: 918-742-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number634
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: