Healthcare Provider Details

I. General information

NPI: 1114377934
Provider Name (Legal Business Name): MRS. STACEY LEE MCCALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LEE OLSON

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12710 E STATE FARM BLVD S
TULSA OK
74146
US

IV. Provider business mailing address

2325 S HARVARD AVE
TULSA OK
74114-3300
US

V. Phone/Fax

Practice location:
  • Phone: 918-986-9090
  • Fax:
Mailing address:
  • Phone: 918-712-4301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: