Healthcare Provider Details

I. General information

NPI: 1861813115
Provider Name (Legal Business Name): KAREN LAKE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 S HARVARD AVE SUITE 110
TULSA OK
74114-6124
US

IV. Provider business mailing address

3010 S HARVARD AVE SUITE 110
TULSA OK
74114-6124
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-1840
  • Fax: 918-749-1841
Mailing address:
  • Phone: 918-749-1840
  • Fax: 918-749-1841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1155
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: