Healthcare Provider Details

I. General information

NPI: 1881679454
Provider Name (Legal Business Name): MARK ALAN GEORGE LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5272 S LEWIS AVE STE 114
TULSA OK
74105-6563
US

IV. Provider business mailing address

5272 S LEWIS AVE STE 114
TULSA OK
74105-6563
US

V. Phone/Fax

Practice location:
  • Phone: 918-219-7377
  • Fax:
Mailing address:
  • Phone: 918-219-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001484
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number709
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: