Healthcare Provider Details

I. General information

NPI: 1861694523
Provider Name (Legal Business Name): ELIZABETH PAGE BROCKWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 S YALE AVE
TULSA OK
74136-3326
US

IV. Provider business mailing address

7701 WARNER AVE #Q237
HUNTINGTON BEACH CA
92647-4773
US

V. Phone/Fax

Practice location:
  • Phone: 918-491-3700
  • Fax: 918-491-5740
Mailing address:
  • Phone: 714-517-6318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 28348
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5868
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: