Healthcare Provider Details

I. General information

NPI: 1366886087
Provider Name (Legal Business Name): VICTORIA DILLARD LBP,LPC,LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12306 S 13TH ST E
WARNER OK
74469-8010
US

IV. Provider business mailing address

12306 S 13TH ST E
WARNER OK
74469-8010
US

V. Phone/Fax

Practice location:
  • Phone: 918-441-7775
  • Fax: 918-989-5544
Mailing address:
  • Phone: 918-441-7775
  • Fax: 918-989-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number29
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3071
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0051
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: