Healthcare Provider Details

I. General information

NPI: 1598641367
Provider Name (Legal Business Name): ROGER DEWAYNE WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S HARRILL AVE
WAGONER OK
74467-5317
US

IV. Provider business mailing address

4103 S YALE AVE STE B
TULSA OK
74135-6002
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-0242
  • Fax: 918-485-0204
Mailing address:
  • Phone: 918-382-7300
  • Fax: 918-382-7302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: